Group Disability Claim Filing Instructions And Employer Initial Claim Form (Page 2 of 4) in pdf

Group Disability Claim Filing Instructions And Employer Initial Claim Form Page 2

American Fidelity Assurance Company

Mail to: AWD Benefits Department

CALIFORNIA

P.O. Box 268898

Oklahoma City, OK 73126-8898

Local Phone # (405)416-7750

Toll Free Phone # 1-800-267-2322

Local Fax# (405)523-5762

Toll Free Fax # 1-888-243-3453

EMPLOYER - INITIAL CLAIM FORM

Employee Name:

Social Security Number:

Occupation:

Hire Date:

Full Time: ❏

Part Time: ❏ Days per week:

________ Hours per day: _________

STATUS OF EMPLOYMENT:

If employee’s status has changed, please check the appropriate box and provide change date below:

Lay Off: ❏

Leave of Absence: ❏

Terminated: ❏

Retired: ❏

PREMIUMS:

Are the employee’s disability premium contributions deducted pre-tax ❏ or post-tax ❏?

What percentage of the disability premiums do you pay? _________%

Are Social Security taxes withheld from employee’s pay check? Yes ❏ No ❏

Date that last disability premiums deducted from payroll:___________ Amount deducted: $__________

SALARY AT TIME OF DISABILITY:

Hourly: $_________ Weekly: $__________ Monthly: $__________

Annually: $__________________

$_____________________

W-2, previous calendar year

Year-to-date, current calendar year

Date last worked? ______________________

Has employee returned to work? Yes ❏ No ❏ Return date: ________________

Full Time ❏ Part Time ❏

Is the employee receiving or eligible to receive any of the following?

Dates Benefits

Yes No

Amount

Company Name and Phone Number

Begin

End

Other Group

Disability

❏

Salary

continuation

❏

Sick Leave

❏

PTO/PPT

❏

Other (Bonus, etc)

❏

Retirement/Pension

❏

Is disability the result of work related injury/illness? Yes ❏ No ❏

If yes, has a Workers' Compensation claim been filed? Yes ❏ No ❏

Please provide name and phone number of Workers' Compensation carrier:

Employer Name:

Office Phone Number:

Fax Phone Number:

Street Address:

City:

State:

Zip Code:

Form completed by: (please print)

Title:

Signature:

Date:

This documents that the above statements are true and complete to the best of my knowledge.

BN-667(CA)-0806

Group Disability Claim Filing Instructions And Employer Initial Claim Form Page 2

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