Request For Individual Cancer, Intensive Care Or Dread Disease Benefits Form Page 3
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4American Fidelity Assurance Company
REQUEST FOR INDIVIDUAL
Mail to: AWD Benefits Department
CANCER, INTENSIVE CARE OR
P.O. Box 268898 | Oklahoma City, OK 73126-8898
Toll Free Phone # 1-800-437-1011
DREAD DISEASE BENEFITS
Local Fax # (405)-523-5762
Toll Free Fax # 1-888-243-3453
See page 1 for fraud statements & filing instructions.
STATEMENT OF INSURED
Insured’s Last Name
First Name
Middle Initial Date of Birth
Account Number
A. ABOUT YOU
Address (City, State, Zip)
Insured’s Social Security Number
Employer - Name
Home Telephone #
Patient’s Name
Patient’s Date of Birth
Patient’s Social Security Number
B. ABOUT THE
PATIENT
Relationship To Insured
q Self
q Husband
q Wife
q Son
q Daughter
q Other
(Specify Relationship)
For dependent child between 21-25 years of age
School
Hours Enrolled
If a full-time student, please enclose a copy of the transcripts.
C. ABOUT CLAIM
Is this claim for
q Cancer Benefits
q Intensive Care Benefits
q Dread Disease Benefits
q Heart Attack/Stroke Benefits
Illness Condition
Has this condition caused previous trouble?
If so, when?
Date first treated
Have you been confined to a hospital? q Yes q No
If “yes,” when From
To
D. DIRECT
Please complete if you desire benefits deposited directly into your bank account.
DEPOSIT
I authorize AFAC to initiate credit entries to my account at the depository named below. This authorization is to
AUTHORIZATION
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
benefits payable under all insurance policies held with AFAC.
Signature __________________________________________________________________________________
NOTE: You must attach a voided check to begin direct deposit.
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.
BN-451-AWD(VT)-1011
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