Initial Credit/closed End Monthly Outstanding Balance Disability Claim Form
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4American Bankers Life Assurance Company of Florida
Time Insurance Company
P.O. Box 977122, Miami, FL 33197-7122
1.800.327.5288
Fax 305.252.6910
Attn: DFS Claims Department
INITIAL CREDIT/CLOSED END MONTHLY OUTSTANDING BALANCE DISABILITY CLAIM FORM
All benefit payments are paid directly to your creditor.
IMPORTANT NOTICE
PLEASE READ CAREFULLY BEFORE COMPLETING YOUR CLAIM FORM
Failure to complete required sections and/or provide requested documentation will delay processing of your claim.
INSTRUCTIONS FOR COMPLETING FORM
If the needed sections are not complete or if the attachments are not attached, the processing of the claim will be
delayed. (Check box after each item is completed.)
1.
Have Section A completed by your creditor or by the financial institution where the coverage was purchased.
Attach a copy of your Certificate of Insurance (including health questions) and Application for Credit
Insurance, if applicable.
If this is a revolving account, have creditor provide printout showing amount due on the date of
disability.
If premiums are paid monthly, please submit a Statement of Account for the month in which disability
occurred.
2.
Complete Section B.
If you are receiving Social Security Disability, please provide us with a copy of your Award Letter or
verification that you are receiving SSDI.
Complete attached Health Insurance Portability and Accountability Act (HIPAA) Authorization pages.
3.
Have your employer complete Section C.
4.
Have your doctor complete Section D.
5.
Follow your creditor’s instructions for mailing the completed claim form.
To avoid late fees, continue to make your payments until you receive notification that your claim has been
approved.
If your claim is approved, a continuing claim form must be submitted every 30 days for additional payments to be made.
After mailing your claim, please allow 15 business days for processing.
Fax completed form and all supporting documentation to 305.252.6910 or mail to:
DFS Claims Department
PO Box 977122
Miami FL 33197-7122
ONCE YOUR CLAIM IS RECEIVED
YOU WILL RECEIVE A LETTER ACKNOWLEDGING RECEIPT OF YOUR CLAIM. THE LETTER
WILL CONTAIN YOUR CLAIM NUMBER.
PLEASE ALLOW 15 BUSINESS DAYS FOR YOUR CLAIM TO BE PROCESSED.
AFTER YOUR CLAIM HAS BEEN PROCESSED, YOU WILL RECEIVE A LETTER ADVISING OF
APPROVAL, DENIAL OR REQUEST FOR ADDITIONAL INFORMATION.
(H)
DISABILITY - CREDIT
C1030-0412
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