Fillable Routine Pregnancy Claim Form (Page 3 of 4) in pdf

American Fidelity Assurance Company

Mail to: AWD Benefits Department

P.O. Box 268898 | Oklahoma City, OK 73126-8898

toll Free Phone # 1-800-437-1011

toll Free Fax # 1-888-243-3453

routine Pregnancy

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

sECtioN 1: EMPLoyEE’s DisABiLity BENEFits APPLiCAtioN

See page 1 for fraud statements.

Full Name: (last, first, middle initial)

maiden Name

Account Number:

Social Security Number:

Date of Birth:

Telephone Number: (including area code)

(

)

mailing Address: (P.O. Box or street, city and zip code)

Occupation:

1. Full names and addresses of all treating physicians: (attach additional list if necessary)

2. If hospitalized, give full name(s) and addresses of hospitals:

(attach additional list if necessary)

____________________________________________________________________

Admit Date

Discharge Date

____________________________________________________________________

Name(s) ____________________________________________

____________________________________________________________________

Address(es) __________________________________________

3. On what date did you last work?__________________________________________

Dates of total disability:

From _________________ Thru __________________

On what date did you return to work?______________________________________

If not returned to work, when do you anticipate returning to work?_____________________________________________________________________

5. If your request for benefits is approved do you want us to withhold Federal Taxes from each benefit check? r Yes

r No

If yes, amount: $ _______________________________________ (indicate amount per month $87.00 minimum)

6. Please identify other income sources and amount of income which you are receiving or may be entitled to receive during this disability:

Workers Comp

r Yes r No $ _________

Other Group Insurance

r Yes r No $ _________

Sick Leave or Wage Continuation

r Yes r No $ _________

Include a copy of your award or denial letter from any source that you have received.

sECtioN 2: EMPLoyEr’s rEPort oF CLAiM

Name of Employer:

Phone No.:

Fax No.:

(

)

(

)

mailing Address: (include street, city, state and zip code)

Name of Employee:

Social Security Number:

Occupation:

Date of Hire:

Does employee participate in Social Security? r Yes r No

If no, hired after 4/1/86? r Yes r No

Have you withheld the employee’s disability premium

for the current month?

Please furnish the percentage of the employee’s AFA disability premium you pay: __________%

r Yes

r No

Are the AFA disability premiums withheld before or after taxes?

r Before

r After

If not, what is the last month you

deducted disability premiums? _____________

sALAry At thE tiME oF DisABiLity:

Hourly: $___________

monthly: $___________

W-2, for previous Calendar Year: $_____________

Year-to-date, Current Calendar Year: $_____________

Number of hours scheduled weekly: ___________

othEr soUrCEs oF iNCoME:

Is the employee receiving or eligible to receive any of the following?

Dates Benefits

Yes

Amount

Company Name and Phone Number

Begin

End

Other Group

Disability

❏

Salary

continuation

❏

Sick Leave

❏

PTO/PPT

❏

Other (Bonus, etc)

❏

Retirement/Pension

❏

Form completed by: (please print)

Title:

Phone Number & Extension:

Employer Name:

Office Phone Number:

Fax Number:

Street Address:

City:

State:

Zip Code:

Signature:

Date:

BN-728 AWD

Routine Pregnancy Claim Form Page 3

Related Articles

Related forms

Related Categories