Fillable Disability Physician Expense Claim Form (Page 2 of 2) in pdf

ATTN: AFES BENEFITS DEPT.

P.O. Box 25160

PHYSICIAN

Oklahoma City, Oklahoma 73125

Toll Free: 1-800-662-1113

EXPENSE

Fax: 1-800-818-3453

(Do NOT use this form when filing for disability)

STATEMENT OF THE INSURED

Name_______________________________________ Date of Birth_____________________ AFA Account #______________

(Policyholder)

Residence Address_______________________________________________________ Social Security No.________________

(Street)

(Town)

(State)

(Zip)

Mailing Address_________________________________________________________

(Street)

(Town)

(State)

(Zip)

I am employed at_________________________________________________________________________________________

(Employer)

(Address)

(City)

(State)

(Zip)

Telephone No.

Home (____)__________________ Work(____)__________________ Occupation______________________

1. Date accident or illness began

2. Nature of illness or accident

3. Was accident or illness work related?

Yes

4. If accident, where and how did it happen? (Explain Fully)

5. Dates of all Treatment - Physician’s Office

Hospital

6. Were you scheduled to work on the day of medical treatment? Yes o No o If no Explain

(semester break, holiday, week-end, etc.):

If yes, were you totally disabled and unable to work one full day on the date of medical treatment?

Yes o

No o

Date unable to work

PLEASE ATTACH DIAGNOSIS AND ITEMIZED CHARGES FROM THE DOCTOR

Signature

Date

I verifiy this information is true and correct.

DIRECT DEPOSIT AUTHORIZATION

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

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

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. California - 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.

AR, DC, LA, NJ, NM, 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. DE, ID,

IN, MN, OH, 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. 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. 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. 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. 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 guilty of insurance fraud.

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

Arizona - For your protection, Arizona law requires the following statement to appear on this

and subjects such person to criminal and civil penalties.

form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

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. Hawaii - For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim

for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Alabama - Any person who knowingly presents a false or fraudulent

claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to

restitution fines or confinement in prison, or any combination thereof. Maryland - Any person who knowingly or willfully presents a false or fraudulent claim for

payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to

fines and confinement in prison.

BN-PE-0514

Disability Physician Expense Claim Form Page 2

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