Spousal Accident Disability Claim Form Page 3
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american Fidelity assurance Company
american Fidelity assurance Company
aCCidEnt
Mail to:
Mail to:
AWD Benefits Department
AFES Benefits Department
PO Box 268898
P.O. Box 25160
disaBiLty
Oklahoma City Oklahoma 73126-8898
Oklahoma City, OK 73125-0160
Phone:
1-800-437-1011
toll Free: 1-800-662-1113
Fax:
1-888-243-3453
Fax: 1-800-818-3453
EMPLoyEr’s rEPort oF CLaiM
Name of Employer:
Phone No.:
(
)
Mailing Address: (include street, city, state and zip code)
Fax No.:
(
)
E
Name of Employee:
Social Security Number:
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Address: (include street, city, state and zip code)
Phone No.:
o
(
)
y
M
Date of Hire:
Occupation: (please attach job description)
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Status of employment at time of disability:
o Full-Time
o Part-Time
o Leave of Absence
o Terminated
o Retired
Number of hours worked per week at time of disability:______________________
Has employee’s status of employment changed? o Yes o No If yes, current status and date of status-change? __________________
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saLary at tiME oF disaBiLity
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a
Annual: $_____________________ Effective Date: _________________________
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y
Date employee last worked:_______________________________
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Has employee returned to work?
r Yes
r No
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If Yes, date returned to work:
i
t
y
Full Time: __________________________
Part Time: ________________________
o
Did Employee’s disability result from employment?
o Yes
o No
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h
If yes, name, address and phone number of Worker’s Compensation carrier: _______________________________________________________
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r
Has employee made a claim for or is entitled to Worker’s Compensation?
o Yes
o No
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Name, address and phone number of any other disability carrier: (include street, city, state and zip code)
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remember - to attach a copy of the applicable school calendar for any contracted employee.
FaiLUrE to do so CoULd rEsULt in dELayEd BEnEFits
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: ________________________________________________________
E-mail Address:______________________________________________ Extension: ____________________________________________________
BN-723-0510
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