Group Disability Claim Filing Instructions And Employer Initial Claim Form printable pdf download

ASSOCIATION and WORKSITE DIvISION

BENEFITS DEPARTMENT

P.O. Box 268898

Oklahoma City, OK 73126-8898

CALIFORNIA

Group Disability Claim Filing Instructions

IMPORTANT: All portions of this claim form must be completed after disability begins to avoid undue

delay in processing claimant’s request for benefits. If you have any questions when completing this

form, please call:

Phone Number - (405) 416-7750 or Toll Free Number - (800) 267-2322

1. Complete "Employee - Initial Disability Claim Form" in full.

2. Have treating physician complete the "Physician - Initial Disability Claim Form"

and return to you.

3. Have your Employer complete the "Employer - Initial Claim Form" and return to you.

4. Complete the Direct Deposit Authorization Agreement below if you prefer funds to be

deposited directly into your checking account.

5. Submit all completed forms to the AWD Benefits Department, P.O. Box 268898,

Oklahoma City, OK 73126-8898 or you may fax all completed forms to our

Toll Free Fax Number - (888) 243-3453.

DIRECT DEPOSIT AUTHORIZATION

IMPORTANT:

Funds from direct deposits will NOT become available to use any earlier than 3-4 business days following the

date the benefits are approved and the credit entry is initiated to your account. If you have already filed a Direct Deposit Authorization

Agreement, do not complete another, unless your Bank or Credit Union account information has changed.

DIRECT DEPOSIT INSTRUCTIONS:

Complete and sign the form below and attach a voided/cancelled check to AUTHORIZATION AGREEMENT. A deposit slip is NOT

acceptable.

AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS:

I authorize American Fidelity Assurance Company to initiate credit entries to my checking account at the depository named below. This

authorization is to remain in full force and effect until the Company has received written notification from me of its termination in such

time and in such a manner as to afford the Company and the Depository opportunity to act on my request.

BANK/CREDIT UNION NAME: ________________________________________________________________________________

MAILING ADDRESS: ________________________________________________________________________________________

CITY, STATE, ZIP CODE: ____________________________________________________________________________________

BANK/CREDIT UNION PHONE NUMBER: ______________________________________________________________________

YOUR SOCIAL SECURITY NUMBER: __________________________________________________________________________

PRINT NAME: ___________________________________________________________DATE: ____________________________

SIGNED: ___________________________________________________________________________________________ ________

ATTACH vOIDED/CANCELLED CHECK

BN-667(CA)-0806

Group Disability Claim Filing Instructions And Employer Initial Claim Form