Fillable Routine Pregnancy Claim Form printable pdf download

AssoCiAtioN and WorKsitE DiVisioN

BENEFITS DEPARTmENT

P.O. Box 268898

Oklahoma City, OK 73126-8898

Routine Pregnancy Claim Filing Instructions

Do not use this form for any benefit other than routine child birth.

Complete Employee’s Disability Benefits Application in full, sign and date the authorization.

Have your Employer complete the Employer’s Report of Claim.

Have the treating physician complete the Attending Physician’s Statement and return to you.

Submit the completed:

A. Employee’s Disability Benefits Application

B. Employer’s Report of Claim

C. Attending Physican’s Statement to the address below or submit via our toll-free fax at 1-888-243-3453

if you have any questions when completing this form, please call: toll Free Number – (800) 437-1011

PAyMENt iNForMAtioN:

Please select one payment option below by checking the appropriate box.

Direct Deposit - If you have

Debit Card - A Debit Card

Check - Check written by

❏

a checking account this is the

account will be applied for

American Fidelity Assurance

most efficient way to receive

through First Fidelity Bank of

and forwarded to your mailing

your benefit payments.

Oklahoma City, OK.

address of Record.

Note: A signature and additional information is required when choosing Direct Deposit or Debit Card option. Be sure to complete the appropriate section below.

ChECKiNG DirECt DEPosit AUthoriZAtioN

iMPortANt: Funds from direct deposits will Not become available to use any earlier than 3-4 business days following the date the benefits are approved and

the credit entry is initiated to your account. If you have already filed a Direct Deposit Authorization Agreement, do not complete another, unless your Bank or

Credit Union account information has changed.

PLEAsE siGN BELoW iF yoU DEsirE BENEFits DEPositED DirECtLy iNto yoUr

BANK ACCoUNt AND AttACh VoiDED/CANCELLED ChECK

I authorize AFAC to initiate credit entries to my account at the depository named below. This authorization is to remain in force and effect until AFAC receives

written notification from me of its termination in such time and in such manner as to affored AFAC and the Depository opportunity to act on it.

this authorization applies to benefits payable under all insurance policies held with AFAC.

DEBit CArD PAyMENt AUthoriZAtioN

iMPortANt: Funds from Debit Card Deposits will Not become available to use any earlier than 3-4 business days following the date the benefits are

approved and the credit entry is initiated to your Debit Card Account. If you have already completed a Debit Card Authorization Agreement and your card is still

active, do not complete another. If you are not sure if you card is still active please contact First Fidelity Bank N.A. at 1(800)299-7047.

AUthoriZAtioN AGrEEMENt For DEBit CArD ACCoUNt: I hereby request and authorize American Fidelity Assurance Company to submit my

application for a Debit Card Account with First Fidelity Bank N.A. of Oklahoma City, Oklahoma under my name. Upon approval and opening of this requested

account. I understand the account will be used for deposits of my benefit payments from American Fidelity Assurance Company. I further understand that

charges will be applied to my account balance from the use of this card; some of those charges include the following.

• ATm Withdrawal (Domestic) = 5 free per month, $3.00 per withdrawal thereafter

• Inactive Account Fee = $5.00

• ATm Withdrawal (International) = $3.00 per withdrawal

after 90 days of account inactivity

• Balance Inquiry = $1.00 per inquiry

• Card Replacement = $10.00

• No charge for IVR phone or website inquiry

• POS (Point-of Sale) Denial Fee = $1.00 per denial

• Pin replacement = $5.00

• Paper Statement = $1.00 per month

• Expedited Card Delivery = $25.00