Form Bn-658-0212 - Group Disability Claim Page 3
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4american Fidelity assurance Company
Mail to:
AFES Benefits Department
P.O. Box 25160
Oklahoma City, OK 73125-0160
Local: (405) 523-5025
toll Free: 1-800-662-1113
Fax: 1-800-818-3453
EMPLoyEr’s rEPort oF CLaiM
Name of Employer:
Phone No.:
(
)
Mailing Address: (include street, city, state and zip code)
Fax No.:
(
)
Name of Employee:
Social Security Number:
E
M
-
-
P
Address: (include street, city, state and zip code)
Phone No.:
L
(
)
o
y
Date of Hire:
Effective date of employee’s coverage:
Occupation: (please attach job description)
M
E
n
Status of employment at time employee last worked:
r Full-Time
r Part-Time
r Leave of Absence
r Terminated
r Retired
t
Number of hours worked per week at time of leave:______________________
In-house days:
First Day ________________
Number of contract days: _______________________ for ____________ school year.
Last Day ________________
Has employee’s status of employment changed? r Yes r No If yes, current status and date of status-change? __________________
Does employee participate in Social Security?
r Yes
r No
If no, hired after 4/1/86?
r Yes
r No
P
r
E
short term ______________%
Please furnish the percentage of the employee’s AFA disability premium you pay:
M
i
Long term ______________%
Are the AFA disability premiums withheld before or after taxes?
U
M
short term Plan r Before r After Long term Plan r Before r After
s
ContraCtEd saLary at tiME oF disaBiLity
s
a
L
Annual: $_____________________ Effective Date: _________________________ r 9 r 10 r 12 Month Work Schedule
a
r 9 r 10 r 12 Month Pay Schedule
r
y
Date employee last worked:_______________________________
Have AFA Disability premiums been withheld
d
i
Has employee returned to work?
r Yes
r No
through the last date worked? r Yes r No
s
a
B
If not, what is the last date disability premiums
i
If Yes, date returned to work:
were deducted? _________________________
L
i
t
Full Time: __________________________
Part Time: ________________________
y
Did Employee’s disability result from employment?
r Yes
r No
If yes, name, address and phone number of Worker’s Compensation carrier: _______________________________________________________
Has employee made a claim for or is entitled to Worker’s Compensation?
r Yes
r No
o
If yes, weekly rate of compensation: $___________________
t
h
Provide:
The final date the employee is entitled to fully paid sick leave __________________________________________________________
E
r
Is this employee eligible to receive any other form of wage continuation? r Yes r No If so, please advise the amount and the final
date the employee is entitled to receive this pay. ____________________________________________________________________
i
n
The first date the employee is entitled to differential/sabbatical pay, if any _______________________________________________ _
C
The last date the employee is entitled to differential/sabbatical pay ___________________________________________________ __
o
M
The daily rate of differential/sabbatical pay $ _____________________________________________________ __________________
E
Name, address and phone number of any other disability carrier: (include street, city, state and zip code)
Is employee eligible for disability retirement benefits?
r Yes
r No
remember - to attach a copy of the applicable school calendar for any contracted employee.
FaiLUrE to do so CoULd rEsULt in dELayEd BEnEFits
I hereby certify that the above named employee is a member of our Group Disability Program. The Information stated above is correct to the best of my
knowledge and belief.
Authorized signature of employer firm or authorized official: _________________________________________________________________________
Title: ______________________________________________________ Date: ________________________________________________________
E-mail Address:______________________________________________ Extension: ____________________________________________________
BN-658-0212
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Parent category: Business