Request For Individual Cancer, Intensive Care Or Dread Disease Benefits Form

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American Fidelity Assurance Company

Mail to: AWD Benefits Department

P.O. Box 268898 | Oklahoma City, OK 73126-8898

Toll Free Phone # 1-800-437-1011

Local Fax # (405)-523-5762

Toll Free Fax # 1-888-243-3453

Cancer Claim Filing Instructions

Use this form for Cancer benefits, Intensive Care benefits, Dread Disease benefits and Heart Attack/Stroke benefits.

CANCER CLAIM FILING INSTRUCTIONS

If you live in the states of GA, OK, SC, or TX please refer to the Special Instructions below for additional steps needed in filing your claim.

Also, regardless of your state of residence, if your policy is one of our C3, C4, C5, or C489 cancer policies (please see bottom left corner of

policy), please refer to the Special Instructions below for additional steps needed in filing your claim.

1) Complete the STATEMENT OF INSURED found on page 3 of this form.

2) Attach ITEMIZED BILLS from each of your providers, with a complete breakdown of charges for each date of service.

3) Have your physician complete the ATTENDING PHYSICIAN’S STATEMENT found on page 4 of this form.

4) If your claim is for a cancer diagnosis, we must have a copy of the PATHOLOGY REPORT from the FIRST PROCEDURE in which cancer

was diagnosed before any benefits can be provided. Your oncologist or your primary treating physician should be able to furnish you with a

copy of this report.

SPECIAL INSTRUCTIONS

1) If your cancer policy is one of our C3, C4, C5, or C489 policies, you must also attach the corresponding Explanations of Benefits (EOB) from your

primary medical coverage that corresponds to each itemized bill requested above.

2) If you live in the states of GA, OK, SC, or TX, and your cancer policy is one of our C3, C4, C5, C6, C7, C8, C9, or C489 policies, you must also attach

the corresponding Explanations of Benefits (EOB) from your primary medical coverage that corresponds to each itemized bill requested above.

3) If you live in the states of GA, OK, SC, or TX, and you are filing for ICU benefits on any of our cancer policies, you must also attach the

corresponding Explanations of Benefits (EOB) from your primary medical coverage that corresponds to each itemized hospital bill requested above.

Incomplete claims may delay processing. Please call us at 1-800-437-1011 if you are unsure which type of policy you have with our

company or what documents you should submit with your claim. We will be happy to assist you.

FRAUD WARNING

Warning: Any person who knowingly and with intent to injure, defraud, or deceive an insurer files a statement of claim containing any false, incomplete, or

misleading information may be guilty of insurance fraud and subject to criminal and civil penalties.

Alaska - A person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete, or misleading information may be

prosecuted under state law.

AR, DC, LA, MD, NJ, NM, RI, TX, and WV - ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR

BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND

CONFINEMENT IN PRISON.

AZ and CA - For your protection, state law requires the following statement to appear on this form: Any person who knowingly

presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Colorado - It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting

to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company

who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder

or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the

department of regulatory agencies.

DE, ID, IN, and OK - WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete,

or misleading information is guilty of a felony.

Florida - Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or

misleading information is guilty of a felony of the third degree.

ME, TN and VA - It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the

company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Kentucky - Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or

conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Minnesota - A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

New Hampshire - Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or

misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

Ohio - Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive

statement is guilty of insurance fraud.

Oregon - Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing

a false statement as to any material fact, may be violating state law.

Pennsylvania - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing

any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime

and subjects such person to criminal and civil penalties.

SIGNATURE OF THE INSURED

Signature of the Insured

Printed Name of the Insured

Date

BN-451-AWD(VT)-1011

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