Fillable Request For Accident Only Policy Benefits Form printable pdf download

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

Accident Only Claim

Filing Instructions

ACCIDENT ONLY CLAIM FILING INSTRUCTIONS:

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

2. Attach copies of all OFFICE NOTES OR MEDICAL RECORDS for treatment of your accidental injury. Also please

provide a POLICE REPORT if available.

3. Itemized bills from your providers and Explanation of Benefits (EOB) from your primary insurance carrier often do not

provide needed information in order to make a proper benefits determination. We may require corresponding office

notes or medical records to review for possible benefits.

4. Discharge papers from the ER or Hospital do not always provide needed information in order to make a proper benefits

determination. We may require corresponding ER or hospital records to review for possible benefits.

5. Please have your employer and physician complete page 4 ONLY IF you have the Accident Only Disability Rider and

are making a claim for Accident Only Disability benefits. If you do not have this disability rider, there is no need to have

your physician complete this form.

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, MD, 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 and subjects such person to criminal and civil penalties.

Arizona - For your protection, Arizona 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.

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.

BN-713-AWD-1011

Request For Accident Only Policy Benefits Form

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