Fillable Form Bn-688(Ca)-0212 - Routine Pregnancy Claim

ATTN: AFES BENEFITS DEPT.

P.O. Box 25160

REQUEST FOR ROUTINE

Oklahoma City, Oklahoma 73125

PREGNANCY BENEFITS

Toll Free: 1-800-662-1113

Fax: 1-800-818-3453

Routine Pregnancy- Do not use this form for any benefit other than routine child birth.

SECTION 1: EMPLOYEE’S DISABILITY BENEFITS APPLICATION

See page 1 for fraud statements.

Full Name: (last, first, middle initial)

Maiden Name

Account Number:

Social Security Number:

Date of Birth:

Telephone Number: (including area code)

(

)

Mailing Address: (P.O. Box or street, city and zip code)

Occupation:

1. Full names and addresses of all treating physicians: (attach additional list if necessary)

2. If hospitalized, give full name(s) and addresses of hospitals: (attach additional list if necessary)

____________________________________________________________________

Admit Date

Discharge Date

____________________________________________________________________

Name(s) ___________________________________________________________________

____________________________________________________________________

Addresses _____________________________________________________________ _ _____

3. On what date did you last work?___________________

Please complete if you desire benefits deposited directly into your bank account.

Dates of total disability:

I authorize AFAC to initiate credit entries to my account at the depository named below. This authorization is to

From _________________ Thru __________________

remain in force and effect until AFAC receives written notification from me of its termination in such time and in

such manner as to afford AFAC and the Depository opportunity to act on it. This authorization applies to

On what date did you return to work?

benefits payable under all insurance policies held with AFAC.

If not returned to work, when do you anticipate returning

Bank/Credit Union Name:

to work?______________________________________

Signature:

NOTE: You must attach a voided check to begin direct deposit.

5. If your request for benefits is approved do you want us to withhold Federal Taxes from each benefit check? r Yes

r No

If yes, amount: $ _______________________________________ (indicate amount per month $86.00 minimum)

6. Are you receiving or eligible to receive other income during this period of disability? r Yes

r No

$ __________ Month

Sick Leave or Wage Continuation:

r Yes

r No

$ __________ Month

Other Disability Coverage:

r Yes

r No

$ __________ Month

Signature: __________________________________________________________________________________________________ Date:___________________________________________

I certify this is true and correct information.

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

I hereby authorize the entities specified below to disclose any information about my entire medical record or benefits payable for this disability 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) the 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, HIV/AIDS (Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome) 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 on 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 may result in a denial or a delay of benefits. I understand that I may revoke this authorization at any time

by writing to AFES Benefits Department, PO Box 25160, Oklahoma City, OK 73125-0160 or by calling, toll-free, 1-800-662-1113. 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 redisclosed and no longer protected by the 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.

Signature (Patient) or Personal Representative (if applicable)

Printed Name (Patient)

Relationship of Personal Representative to Patient

Date

If authorization is supplied by a personal representative a description of the authority to act on behalf of the Insured must be included.

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

SECTION 2: EMPLOYER’S REPORT OF CLAIM

Name of Employer:

Phone No.:

Fax No.:

(

)

(

)

Mailing Address: (include street, city, state and zip code)

Name of Employee:

Social Security Number:

Occupation:

Date of Hire:

Does employee participate in Social Security?

r Yes

r No

If no, hired after 4/1/86?

r Yes

r No

Have you withheld the employee’s disability premium for the current month?

Please furnish the percentage of the employee’s AFA disability premium you pay: __________%

r Yes

r No

Are the AFA disability premiums withheld before or after taxes?

r Before

r After

If not, what is the last month you deducted disability premiums? _____________

CONTRACTED SALARY AT TIME OF DISABILITY

r 9

r 10

r 12 Month Work Schedule

Annual: $ __________________________________ Effective Date: _______________________________ Number of hours worked per week at time of disability ____________________.

Number of Contract days: ______________ for _______________ school year.

Date employee last worked:_____________________________ Has employee returned to work? r Yes

r No If Yes, date returned to work: Full Time: ___________________

Provide: The final date the employee is entitled to fully paid sick leave_________________________________________________________________________________________

The first date the employee is entitled to differential________________________________________________________________________________________________

The last date the employee is entitled to differential________________________________________________________________________________________________

The daily rate differential/sabbatical pay $________________________________________________________________________________________________________

I hereby certify that the above named employee is a member of our Group Disability Program. The Information stated above is correct to the best of my knowledge and belief.

Authorized signature of employer firm or authorized official: ______________________________________________________________________________________________________________ __

Title: _______________________________________________________________________________________________ Date: ________________________________________________ __

BN-688(CA)-0212

Form Bn-688(Ca)-0212 - Routine Pregnancy Claim - 2012 Page 2

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