Spousal Accident Disability Claim Form Page 3
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4American Fidelity Assurance Company
Mail to:
SPOUSAL
AFES Benefits Department
P.O. Box 25160
ACCIDENT
Oklahoma City, OK 73125-0160
DISABILTY
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.:
(
)
E
Name of Employee:
Social Security Number:
M
-
-
P
L
Address: (include street, city, state and zip code)
Phone No.:
O
(
)
Y
M
Date of Hire:
Occupation: (please attach job description)
E
N
T
Status of employment at time of disability:
o Full-Time
o Part-Time
o Leave of Absence
o Terminated
o Retired
Number of hours worked per week at time of disability:______________________
Has employee’s status of employment changed? o Yes o No If yes, current status and date of status-change? __________________
S
SALARY AT TIME OF DISABILITY
A
L
A
Annual: $_____________________ Effective Date: _________________________
R
Y
Date employee last worked:_______________________________
D
I
S
Has employee returned to work?
r Yes
r No
A
B
I
L
If Yes, date returned to work:
I
T
Y
Full Time: __________________________
Part Time: ________________________
O
Did Employee’s disability result from employment?
o Yes
o No
T
H
If yes, name, address and phone number of Worker’s Compensation carrier: _______________________________________________________
E
R
Has employee made a claim for or is entitled to Worker’s Compensation?
o Yes
o No
I
Does the employee have other group disability insurance? o Yes
o No
N
C
Name, address and phone number of any other disability carrier: (include street, city, state and zip code)
O
M
E
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-723-1114
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