Form Abj16689-3 - Outpatient Physician'S Treatment Claim Form

Important: To avoid delay, please sign authorization below.

I authorize any physician, medical practitioner, hospital, clinic or other medical facility, insurance company, the Medical Information Bureau or other

organization, institution or person, that has records or knowledge of me or my health to give to American Heritage Life Insurance Company (AHL), its

subsidiaries or its reinsurers any information relating to my claim. A copy of this authorization is as valid as the original. This authorization applies to any

dependent on whom a claim is filed. This authorization is valid for a period of 24 months from the date signed. I understand that I may revoke this

authorization at any time by notifying AHL in writing of my desire to do so. I or my representative may receive a copy of this authorization by supplying

policy number(s) and Insured’s name in a written request to the company. (In MAINE – I understand that revocation of this authorization may be a basis

for denying insurance benefits. Failure to sign an authorization statement may impair the ability of a regulated insurance agency to evaluate claims and

may be a basis for denying a claim for benefits.)

Sign here: _______________________________________________ Date:_______________________

Check here if address is new

Claimant

Mailing Address:_________________________________City:____________________State:_______ Zip: __________Telephone No:. (

)____ ___

ILLINOIS INTEREST STATEMENT: For contracts issued in and residents of Illinois, unless payment is made within

fifteen (15) days from the date of receipt by the company of due proof of loss, interest shall accrue on the proceeds

payable because of the death of the insured, from date of death, at the rate of 9% on the total amount payable or the

face amount if payments are to made in installments until the total payment or the first installment is paid.

FRAUD WARNINGS BY STATE

NOTICE IN 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.

NOTICE IN ALASKA, ARKANSAS, KENTUCKY, LOUISIANA, MAINE, NEW JERSEY, NEW MEXICO, AND

VIRGINIA: Any person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim

containing false, incomplete or misleading information may be prosecuted under state law.

NOTICE IN 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.

NOTICE IN CALIFORNIA: For your protection, California law requires the following to appear on this form. Any

person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject

to fines and confinement in state prison.

NOTICE IN 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.

NOTICE IN DELAWARE, IDAHO, INDIANA, MINNESOTA, AND OKLAHOMA: Any person who knowingly and with

intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading

information is guilty of a felony.

NOTICE IN DISTRICT OF COLUMBIA: FRAUD NOTICE: It is a crime to provide false or misleading information to an

insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In

addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the

applicant.

NOTICE IN 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.

NOTICE IN 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.

NOTICE IN 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.

NOTICE IN NEW YORK: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of

the claim for each such violation.

ABJ16689-3

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Form Abj16689-3 - Outpatient Physician'S Treatment Claim Form - 2013 Page 3

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