Request For Accident Only Policy Benefits Form Page 3
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4American Fidelity Assurance Company
REQUEST FOR
Mail to: AWD Benefits Department
P.O. Box 268898
ACCIDENT ONLY
Oklahoma City, OK 73126-8898
POLICY BENEFITS
Toll Free Phone # 1-800-437-1011
Local Fax # (405)-523-5762
Toll Free Fax # 1-888-243-3453
See page 1 for fraud statements and filing instructions. Attach copies of all OFFICE NOTES OR MEDICAL RECORDS for
treatment of your accidental injury. Also please provide a POLICE REPORT if available.
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 #
B. ABOUT THE
PATIENT INFORMATION
Patient’s Name
Patient’s Birth Date
Patient’s Social Security Number
(CHECK ONE)
PATIENT
For whom
If Claim is for a Dependent Child
If Dependent Child is between
q Self
q Son
q Yes
q Yes
do you
Under 21, is Such Child Living in
age 21 and 25 years old is (s)he
q Wife
q Daughter
make this
Your Household?
a full-time student?
q Husband q Other
q No
q No
request?
If yes, submit transcripts or grade reports.
identify
C. ABOUT THE
Date of Accident
Type of Injury
ACCIDENT
Describe how the accident occurred
Were you transported to an emergency center or hospital by ambulance? _____ Yes
_____ No
Were you hospital confined due to this accident? _____ Yes
_____ No
If yes, give admit and discharge dates, and name and address of hospital. admitted ____/____/____ discharged ____/____/____
Are you making a claim under your Accident Only Disability benefit? _____ Yes
_____ No
IF YES, COMPLETE THE BACK OF
THIS FORM.
DIRECT DEPOSIT AUTHORIZATION
Please complete if you desire benefits deposited directly into your bank account.
I authorize American Fidelity Assurance Company 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.
BN-713-AWD-1011
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