Maternity Disability Claim Form
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4MATERNITY DISABILITY CLAIM FORM
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 or
visit our website at
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.
Mail or Fax Your Claim to:
American Heritage Life Insurance Company
1776 American Heritage Life Drive, Jacksonville, FL 32224
Fax: 1-866-424-8482
If you would like to have claim benefits automatically deposited into your bank account, please complete and send our
ACH
form
(ABJ16661).
This
form
can
be
found
on
our
website
at
or
/mybenefits.
POLICYHOLDER / CERTIFICATEHOLDER INFORMATION:
POLICY NUMBER(s): ____________________; ____________________; _____________________; ____________________
POLICYHOLDER INFORMATION:
First Name: __________________________________________ MI: ________ Last Name: __________________________________________
□
□
Social Security Number: ________________________________ Date of Birth: _____/_____/_____
Age: ________
Male
Female
Mailing Address:
_________________________________________________________________________
Apt#: __________
□
Check here if
address is new
City: ________________________________________________ State: ________________
Zip: ___________
Phone #:(____)_________________
E-mail: _________________________________________________
PATIENT INFORMATION: (If different)
First Name: __________________________________________ MI: ________ Last Name: __________________________________________
□
□
Social Security Number: ________________________________ Date of Birth: _____/_____/_____
Age: ________
Male
Female
□
□
□
□
Relation to Insured:
Self
Spouse
Child
Other
DISABILITY BENEFITS:
Please complete the questions below and attach the required documentation for review of your
Maternity Disability claim. If additional information is needed, you will be notified. For assistance, please contact our
Customer Care Center at 1-800-348-4489.
□
□
Is your disability due to
Delivery or
Complications of Pregnancy?
If Complications of Pregnancy, please list: ______________________________________________________________________
□
□
What is your expected due date
Delivery Date
Normal Delivery
C-Section
: ______/_____/______
: _____/_____/_____
(Expected recovery following delivery is 6 weeks for vaginal delivery & 8 weeks for c-section delivery. This includes the elimination period)
□
□
What was the first date you were unable to work?
Have you returned to work?
_____/_____/_____
Yes
No
Returned Part Time or Partial Duties on:
Returned Full Time or Full Duties on:
_____/_____/_____
_____/_____/_____
PLEASE HAVE YOUR PHYSICIAN COMPLETE AND SIGN THE MATERNITY ATTENDING PHYSICIAN’S STATEMENT.
PLEASE HAVE YOUR EMPLOYER COMPLETE AND SIGN THE EMPLOYER’S STATEMENT
.
CERTIFICATION: Please read and sign below
I acknowledge the receipt of the Department of Insurance Claim Fraud Statements provided with this claim packet. I have read the notices and I am
aware that it is a crime to fill out this form with facts I know are false or to leave out facts I know are relevant and important. I certify that the answers
given on this claim form are true, complete, and correctly recorded. Please also remember to sign and date the attached authorization
required to process your claim.
Patient’s
:___________________________________
: ________________________________
Signature
Print Name
Date: _____/_____/_____
Remember it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important.
Please check to be sure all information is correct before signing. Please refer to the fraud notice specific to your state.
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