Form Abj10364-2 - Cancer / Specified Disease / Icu / Heart / Stroke Claim - 2012

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CLAIM FORM AND INSTRUCTIONS
If you have any questions regarding benefits available, or how to file your claim, or if you
would like to appeal any determination, please contact our Customer Care Center at
1-800-348-4489 8:00 A.M. to 8:00 P.M. Eastern Standard Time
The furnishing of this form, or its acceptance by the Company as proof, must not be construed as an admission of any
liability on the part of the Company, nor a waiver of any of the conditions of the insurance contract.
INSTRUCTIONS FOR FILING CANCER / SPECIFIED DISEASE / ICU / HEART / STROKE CLAIMS
To avoid processing delays, please fill out the sections which apply to your specific claim.
Include your policy number(s). To obtain your policy number(s) call 1-800-348-4489.
You may fax your claim to us at 1-866-424-8482. Please be assured that your claim will receive our immediate
attention. If you would like to receive your claim proceeds even faster, Allstate Benefits can automatically deposit
them into your bank account by completing and returning our ACH form (ABJ16661). This form can be found on our
website at
or electronically at /mybenefits. Additional claim forms
are available on our
website.
American Heritage Life Insurance Company
You may mail your claim to:
P.O. Box 43067
Jacksonville, Florida 32203-3067
If you are filing a claim within the first 24 months your policy is in force, additional information may be required.
POLICYHOLDER / CERTIFICATEHOLDER
Employer Name (Company):
Occupation:
1.
Policyholder’s Name: First:
Middle:
Last:
E-mail:
Policy Number:
Social Security Number:
Date of Birth:
/
/
Male
Female
MO/DAY/YR
2.
Home Number: (
)
PATIENT’S INFORMATION
3.
Name: First:
Middle:
Last:
4.
Date of Birth:
/
/
Age:
Social Security Number:
Male
Female
MO/DAY/YR
5.
This person is your:
(ex: self, wife, son, etc.) Is he/she a full-time student?
Yes
No
If yes, please submit proof of student status.
INSTRUCTIONS FOR FILING CANCER, SPECIFIED DISEASE, INTENSIVE CARE, AND HEART / STROKE CLAIMS
CANCER CLAIMS:
A pathology report diagnosing cancer must accompany your first claim for that diagnosis of cancer. (The hospital or doctor will furnish
this report to you at your request.) If the diagnosis of cancer was made by clinical information instead of pathological means, please
submit the clinical evidence that established a positive diagnosis of cancer.
Include a copy of your itemized hospital billing if you were hospitalized.
Have the doctor complete Attending Physician’s Statement and attach an itemized billing showing the diagnosis, services provided
and the actual charges made to you.
Any other bills pertaining to this claim, such as anesthesia, chemotherapy or radiation treatments, ambulance, lodging, or travel, may be
forwarded to this office.
Transportation and Lodging - Please review your policy to determine what expenses are covered. Send us a statement detailing your
transportation and lodging expenses. This information should include mileage, where you traveled from and to, lodging receipts and
medical verification of treatment for this time.
SPECIFIED DISEASE:
The results of tissue specimen, culture(s) and/or titer(s) or other diagnostic studies, which initially diagnosed the specified disease, must
accompany your first claim. Include a copy of your itemized hospital billing and Attending Physician’s Statement.
HOSPITAL INCOME AND INTENSIVE CARE CLAIMS:
Please send a copy of your hospital bill showing charges and number of days in the intensive care unit.
If the hospital bill fails to give the diagnosis, Attending Physician’s Statement must be completed by the doctor.
A copy of the police report is required for all accidents investigated by any law enforcement agency.
HEART STROKE CLAIMS:
Submit diagnostic test result showing a diagnosis of disease of the heart, heart attack or stroke.
ABJ10364-2
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