Form Awd103651w-1 - Group Critical Illness Claim

WALMART GROUP CRITICAL ILLNESS

CLAIM FORM AND INSTRUCTIONS

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 the AWD Walmart Claim Department

at 1-800-514-9525, 8:00 A.M. to 8:00 P.M. Eastern Standard Time or 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.

•

To avoid delays in processing please fill out the sections which apply to your specific claim.

•

Include your certificate number. To obtain your certificate number, you may call

1-800-514-9525

or visit our website

at .

•

You may fax your claim to us at

1-877-423-8804

or scan and electronically submit your claim through:

•

You may also mail your claim to:

American Heritage Life Insurance Company

P.O. Box 41488

Jacksonville, Florida 32203-1488

Please be assured that your claim will receive our prompt attention. You will usually receive a response from us,

including mail time, within 10 business days following the receipt of your claim. The length of time in the mail will

depend on your location.

•

Additional claim forms are available on our website at .

INSURED AND PATIENT INFORMATION

1. Insured’s Name: First:

Middle:

Last:

E-mail:

Certificate Number:

Social Security Number:

Date of Birth:

Male

Female

MO/DAY/YR

2. Daytime Phone Number: (

)

Evening/Cell Phone Number: (

)

3. Occupation:

PATIENT’S INFORMATION

4. Name: First:

Middle:

Last:

5. Date of Birth:

Age:

Male

Female

MO/DAY/YR

6. This person is your:

(self, wife, child, etc.) If your child is over 18 years of age, is he/she a full-

time student?

Yes

If yes, please send proof of student status.

INSTRUCTIONS FOR FILING CRITICAL ILLNESS CLAIMS:

The results of a tissue specimen, culture(s) and/or titer(s) or other diagnostic studies, which initially diagnosed

the specified disease, must accompany your claim. Include a copy of your itemized hospital billing and

Attending Physician’s Statement. Thank You.

AWD103651W-1

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Form Awd103651w-1 - Group Critical Illness Claim - 2011

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