Group Disability Claim Filing Instructions And Employer Initial Claim Form (Page 3 of 4) in pdf

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

EMPLOYEE - INITIAL DISABILITY CLAIM FORM

Warning: For your protection California law requires the following to appear on this form. Any person who knowingly presents false or

fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Name:

Social Security Number:

Date of Birth:

Complete Mailing Address:

Complete Resident Address:

Telephone Number:

Do you have dependents under age 18? Yes ❏ No ❏ If yes, please list dependent names and birth dates below:

1) Please list medical condition or injury causing disability:

2) If disability is the result of an accident, please explain

where, when, and how accident happened:

3) Is your disability the result of your employment? Yes ❏ No ❏ If yes, please submit copy of Workers' Compensation award or denial letter.

4) Please list all dates of medical treatment pertaining

5) Have you ever had or been treated for same or

to current disability:

similar condition? Yes ❏ No ❏ If yes, please explain:

6) Please list name and phone number of treating physician(s):

7) Date Last Worked:

8) If you have not returned to work,

9) If your request for benefits is approved, do you want

what is the anticipated return date?

Federal Taxes withheld from each benefit check?

Yes ❏ No ❏

❏ Full Time: ______________________

Date Returned to Work:

If yes, please indicate dollar amount below:

❏ Part Time:______________________

$_______________

(Minimum amount required is $87 per month.)

10) Please identify other income sources and amounts of income which you are receiving or may be entitled to receive during this disability:

Social Security - Disability ❏ Retirement ❏

Yes ❏ No ❏

$__________

V.A. Benefits

Yes ❏ No ❏

$___________

Dependent Social Security

Yes ❏ No ❏

$__________

Sick Leave or Wage Continuation

Yes ❏ No ❏

$___________

State Disability

Yes ❏ No ❏

$__________

Retirement (normal, early, or disability)

Yes ❏ No ❏

$___________

Other Group Disability Coverage

Yes ❏ No ❏

$__________

Include a copy of your award or denial letter from any source that you have received.

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

I hereby authorize the entities specified below to disclose any information about my entire medical record and history of treatment for physical and/or emotional illness

to include psychological testing, except psychotherapy notes, to individuals representing American Fidelity Assurance Company (AFAC) who are involved in determining

whether I am eligible for benefits under my insurance coverage. Those so authorized are: a) licensed physicians or medical practitioners; b) hospitals, clinics or

medically-related facilities; c) health plans: d) Veteran’s Administration; e) past or present employers; f) pharmacy; g) insurance companies; h) Social Security

Administration; i) retirement systems; j) Department of Motor Vehicles, and k) Workers’ Compensation carrier.

NOTICE: Information authorized for release may include information on communicable or venereal diseases such as hepatitis, syphilis, gonorrhea, Human

Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) or other conditions for which you may have been treated. This authorization excludes

disclosure of the result of a test for HIV if you have tested HIV positive but have not developed symptoms of the disease AIDS. Such test results shall not be discovered

or published. Nothing in the caveat will prohibit this authorization from including the fact that you have AIDS.

I understand that I may refuse to sign this authorization; however, if I do not sign the authorization, my failure to sign the authorization may result in a denial of benefits.

I understand that I may revoke this authorization at any time by writing to American Fidelity Assurance Company, AWD Benefits Department, P.O. Box 268898, Oklahoma

City, Oklahoma 73126-8898 or calling toll free 1-800-267-2322. I understand that my right to revoke this authorization is limited to the extent that AFAC has taken action in

reliance on the authorization; or, the law provides AFAC with the right to contest my insurance coverage or a claim under my insurance coverage. A copy of this

authorization will be as valid as the original. I understand that if protected health information is disclosed to a person or organization that is not required to comply with

federal privacy regulations, the information may be re-disclosed and no longer protected by federal privacy regulations.

For health insurance coverage, this authorization will expire twenty-four months from the date it is signed or upon termination of my insurance policy, whichever occurs

first. For insurance coverage other than health insurance, this authorization will expire twenty four months from the date it is signed or upon expiration of my claim for

benefits, whichever occurs first. For Arizona residents, release of HIV/AIDS released information can only be disclosed for a period not to exceed 180 days from the date

shown below.

Signature ____________________________________________ Print Insured’s/Patient Name ______________________________________ Date__________________

Please retain a copy for your personal records, or you may request a copy from our company

FAILURE TO SIGN & DATE FORM WILL DELAY BENEFITS

BN-667(CA)-0806