Form Awd103651w-1 - Group Critical Illness Claim - 2011 Page 2

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PLEASE CHECK THE BOX(S) THAT BEST DESCRIBE YOUR CLAIM
Following are the benefits available under your Wal-Mart Group Critical Illness Policy. Please check the benefit(s) you
believe may be due based upon your condition. You will need to attach medical record documentation of your condition.
*Physician, clinic, or facility receipt showing the specific
WELLNESS BENEFIT
wellness exam performed and the date it was provided
CRITICAL ILLNESS BENEFIT (Please check the illness which you are requesting benefits)
*Electrocardiograph proof and lab reports showing elevated
Heart Attack
cardiac enzymes or biochemical markers
Stroke
*Medical record documentation of permanent neurological deficit
Transient Ischemic Attack (TIA)
*Medical record documentation of a TIA
Coronary Artery By-Pass Surgery
*Medical record or billing proof of procedure
Invasive Cancer
*Pathology report
Carcinoma in situ
*Pathology report
*Medical record documentation showing proof of failure to
End Stage Renal Failure
both kidneys and proof of dialysis or transplant
*Medical record documentation by psychiatrist or neurologist to
Alzheimer’s Disease
include proof of inability to perform 3 or more activities of daily living
SPECIFIED DISEASES: (Please check the illness for which you are requesting benefits)
Addison’s Disease
Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease)
Cerebrospinal Meningitis (bacterial)
Cerebral Palsy
Cystic Fibrosis
Diphtheria
Encephalitis
Huntington’s Chorea
Legionnaire’s Disease
*Confirmation by culture or sputum
Malaria
Multiple Sclerosis
Muscular Dystrophy
Myasthenia Gravis
Necrotizing fasciitis
Osteomyelitis
Poliomyelitis
Rabies
*Also eligible for Recurrence Benefit
Sickle Cell
Systemic Lupus
Systemic Sclerosis
Tetanus
Tuberculosis
RECURRENCE BENEFIT
TRANSPORTATION BENEFIT
WAIVER OF PREMIUM
LODGING BENEFIT
NATIONAL CANCER INSTITUTE (NCI) EVALUATION
MAJOR ORGAN TRANSPLANT OPTIONAL BENEFIT RIDER
SIGN THIS PART ONLY IF YOU WISH TO ASSIGN YOUR BENEFITS TO A PROVIDER OR A FACILITY
I request that American Heritage Life Insurance Company send benefits to someone other than me. Please send benefits available to the name and
address shown below:
Name
Relationship
Address
Provider or Facility Tax Identification Number
City
State
Zip
Signature of Insured
Date
AWD103651W-1
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