American Fidelity Assurance Company
Mail to:
AFES Benefits Department
P.O. Box 25160
Oklahoma City, OK 73125-0160
Toll Free Phone # 1-800-662-1113
T
oll Free Fax #
1-800-818-3453
ATTENDING PHYSICIAN’S STATEMENT
Name of Patient: Date of Birth: Account Number:
Diagnosis: (including complications) ICDA Code:
Is disability due to injury or sickness arising out of or in the course of patient’s employment?
❏
Yes
❏
No
Is disability the result of pregnancy?
❏
Yes
❏
No
If yes, type of delivery: ___________________________
Date pregnancy was diagnosed? ____/____/____ Date of delivery:(if delivered) ____/____/____ Expected date of delivery? ____/____/____
When did symptoms first appeared or accident happen? Date patient first consulted you for this condition?
Has the patient ever had the same or similar condition?
❏
Yes
❏
No If yes, indicate when and describe:
Was the patient referred to you?
❏
Yes
❏
No If yes, full name and address of referring physician:
Frequency of treatment:
❏
Monthly
❏
Weekly
❏
Other
If not under your regular care and attendance please explain.
Date of next appointment : _______/______/______
Nature of treatment being rendered (including surgery and any medications being prescribed)
List all dates of treatment or medical attention since the disability began:
Is patient still under your care for this condition?
❏
Yes
❏
No If no, please provide the name of the current treating physician:
Has the patient been confined to a hospital?
❏
Yes
❏
No Admitted:
_____/_____/_____
Discharged:
_____/_____/_____
If yes, give admit and discharge dates along with name and address of hospital. Admitted:
_____/_____/_____
Discharged:
_____/_____/_____
Name:___________________________________________________ Address: ___________________________________________________
California Physicians: Please answer the following question with respect to your patient’s disability:
Patient was continuously totally disabled (unable to work)
1. Own occupational ❏ Yes ❏ No From: ___________ thru _________ 2. Any occupation ❏ Yes ❏ No From: ________ thru ________
Total Disability from own occupation is defined as a disability that Total Disability from any occupation is defined as: disability that renders one
renders one unable to perform with reasonable continuity the substantial unable to engage with reasonable continuity in another occupation in which
and material acts necessary to pursue his usual occupation in the usual
he could reasonably be expected to perform satisfactorily in light of his age,
and customary ways.
education, training, experience, station in life, physical and mental capacity.
If the patient is currently disabled, what is the anticipated length of disability?
❏
1-2 Months
❏
2-3 Months
❏
3-6 Months
❏
6-12 Months
❏
More than 12 Months
❏
Permanent
When, in your opinion will the patient recover sufficiently to return to work?
Functional Limitations that render your patient totally disabled:
Current Treatment Plan:
Attention Physician:
This form documents your verification that the above named individual is totally disabled from either their or any other occupation.
Y
our
signature generates disbursement of disability benefits.
You will be asked periodically for updates related to this individual’s disability status and treatment plan.
Attending Physician’s Name: (print) Specialty: Telephone #: Fax #:
Street Address: City: State: Zip Code:
Signature: Federal Tax ID #: Date:
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BN-658(CA)0506
______/______/______
______/______/______
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Dates of partial disability? From: ____________________ Through: ____________________
BN-658(CA)0506
Group Disability Claim
Filing Instructions
(Not for use when filing for Physician’s Expense Benefits)
CALIFORNIA
Disability claim forms should be completed
after you become disabled.
1. Complete Employee’s Disability Benefits Application in full.
2. Have the treating physician complete the Attending Physicians Statement
and return to you.
3. Have your Employer complete the Employer’s Report of Claim.
4. Submit the completed:
A. Employee’s Disability Benefits Application
B. Employers Report of Claim
C. Attending Physician’s Statement
to the address below or submit via our toll-free fax @ 1-800-818-3453
5. Please complete if you desire benefits deposited directly into your bank account.
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 afford AFAC and the
Depository opportunity to act on it.
Signature: ___________________________________________________________
NOTE: You must attach a voided check to begin direct deposit.
All portions of this form package must be completed to avoid undue delay in
processing claimant’s request for benefits. If you have any questions regarding
completion of this form please call:
Toll Free Phone # 1-800-662-1113
Educational Services Division
Benefits Department
P.O. Box 25160
Oklahoma City
, Oklahoma 73125-0160
www.afadvantage.com
American Fidelity Assurance Company
Mail to:
AFES Benefits Department
P
.O. Box 25160
Oklahoma City, OK 73125-0160
Toll Free Phone # 1-800-662-1113
Toll Free Fax # 1-800-818-3453
www
.afadvantage.com
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:
Address: (include street, city, state and zip code) Phone No.:
Date of Hire: Effective date of employee’s coverage: Occupation: (please attach job description)
Status of employment at time of disability:
❏
Full-Time
❏
Part-Time
❏
Leave of Absence
❏
Terminated
❏
Retired
Number of hours worked per week at time of disability:______________________
Number of contract days: _______________________ for ____________ school year.
Has employee’s status of employment changed?
❏
Yes
❏
No If yes, current status and date of status-change? __________________
Does employee participate in Social Security?
❏
Yes
❏
No If no, hired after 4/1/86?
❏
Yes
❏
No
Please furnish the percentage of the employee’s AFA disability premium you pay: Short Term Plan _____________
Are the AFA disability premiums withheld before or after taxes? On Long Term Plan _____________
Short Term Plan
❏
Before
❏
After Long Term Plan
❏
Before
❏
After
CONTRACTED SALARY AT TIME OF DISABILITY
Monthly: $__________________ Effective Date: ____________________________
❏
9
❏
10
❏
12 Month Work Schedule
Annual: $______________________ Effective Date: ________________________
❏
9
❏
10
❏
12 Month Work Schedule
Date employee last worked:_______________________________ Have you withheld the employee’s disability premium for the current month?
Has employee returned to work?
❏
Yes
❏
No
❏
Yes
❏
No
If Yes, date returned to work: If not, what is the last month you deducted disability premiums?
Full Time: ___________________Part Time: _________________ __________________________________
Did Employee’s disability result from employment?
❏
Yes
❏
No
If yes, name, address and phone number of Worker’s Compensation carrier: _______________________________________________________
Has employee made a claim for or entitled to W
orker
’
s Compensation?
❏
Y
es
❏
No
If yes, weekly rate of compensation: $___________________
Provide:
The final date the employee is entitled to fully paid sick leave __________________________________________________________
The
first date the employee is entitled to differential/sabbatical pay, if any ________________________________________________
The
last date the employee is entitled to differential/sabbatical pay _____________________________________________________
The daily rate of differential/sabbatical pay $ ________________________________________________________________________
Name, address and phone number of any other disability carrier: (include street, city, state and zip code)
Is employee eligible for disability retirement benefits?
❏
Yes
❏
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:
Date: ______________________ Signature: ________________________________________________________ Title: _________________________
E-mail address: _____________________________________________________________________________________________________________
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Inhouse days:
First Day ________________
Last Day ________________
Mail to: AFES Benefits Department
P.O. Box 25160
Oklahoma City, OK 73125-0160
Toll Free Phone # 1-800-662-1113
Toll Free Fax # 1-800-818-3453
www.afadvantage.com
EMPLOYEE’S DISABILITY BENEFITS APPLICATION
For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.
Full Name: (last, first, middle initial) Maiden Name Account Number:
Residence: (street, city, state and zip code) Social Security Number:
Mailing Address: (P.O. Box or street, city and zip code) Date of Birth:
Telephone Number: (including area code)
❒
Single
❒
Married
❒
Widowed
❒
Divorced
Occupation: Has your employment terminated? If so, date:
Names & birth dates of _____________________________/_____/_____ _____________________________/_____/_____
_____________________________/_____/_____ _____________________________/_____/_____
1. Date accident or illness began: 2. If accident, explain where and how it happened?
3. Have you ever had the same or similar condition in the past? ❒ Yes ❒ No
If yes, names and address of treating physicians and/or hospitals:
4. Nature of illness or injury: 5. Dates of medical treatment:
6. If hospitalized give full name(s) and addresses
of hospitals: (attach additional list if necessary)
7. Full names and addresses of all treating physicians: 8. Is your disability related to your employment/occupation?
❒
Yes
❒
No
(attach additional list if necessary)
If yes, have you or do you intend to file for Worker’s Compensation?
❒
Yes
❒
No
10. If your request for benefits is approved do you want us to withhold Federal Taxes from each benefit check?
❒
Yes
❒
No
If yes, amount: $ _______________________ (indicate amount per month $86.00 minimum)
11. Identify other income sources and amount of income for which you are receiving or may be entitled to receive during this disability
Your Social Security: (disability or retirement) ❒ Yes ❒ No $_______Mo. V.A. Benefits: ❒ Yes ❒ No $_______Mo.
Dependent Social Security:
❒ Yes ❒ No $_______Mo. Worker’s Compensation: ❒ Yes ❒ No $_______Mo.
Sick Leave or Wage Continuation: ❒ Yes ❒ No $_______Mo. Other Disability Coverage: ❒ Yes ❒ No $_______Mo
Retirement: (normal early or disability) ❒ Y
es
❒ No
$_______Mo. (identify)__________________________________________________
State Disability Income ❒ Yes ❒ No $_______Mo.
Signature: _____________________________________________________________________ Date: ____________________________________________________
I certify this information is true and correct
.
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
I hereby authorize the entities specified below to disclose any information about my entire medical record and history of treatment for physical and/or emotional illness to include psychological testing,
except psychotherapy notes, to individuals representing American Fidelity Assurance Company (AFAC) who are involved in determining whether I am eligible for benefits under my insurance coverage.
Those so authorized are: a) licensed physicians or medical practicioners; b) hospitals, clinics or medically-related facilities; c) health plans; d) Veteran’s Administration; e) past or present employers;
f) pharmacy; g) insurance companies; h) the Social Security
Administration; i) retirement systems; j) Department of Motor Vehicles; and k) Workers’ Compensation Carrier.
NOTICE: Information authorized for release may include information on communicable or venereal diseases such as hepatitis, syphilis, gonorrhea, HIV/AIDS (Human Immunodeficiency Virus/Acquired
Immune Deficiency Syndrome) or other conditions for which you may have been treated. This authorization excludes disclosure of the result of a test for HIV if you have tested HIV positive but have not
developed symptoms of the disease AIDS. Such test results shall not be discovered or published. Nothing in this caveat will prohibit this authorization from including the fact that you have AIDS.
I understand that I
may refuse to sign this authorization; however
, if I
do not sign the authorization, my failure to sign the authorization may result in a denial or a delay of benefits.
I understand that I may revoke this authorization at any time by writing to AFES Benefits Department, PO Box 25160, Oklahoma City, OK 73125-0160 or by calling, toll-free, 1-800-662-1113. I understand
that my right to revoke this authorization is limited to the extent that: AFAC has taken action in reliance on the authorization; or, the law provides AFAC with the right to contest my insurance coverage
or a claim under my insurance coverage. A copy of this authorization will be as valid as the original.
I understand that if protected health information is disclosed to a person or organization that is not required to comply with federal privacy regulations, the information may be redisclosed and no longer
protected by the federal privacy regulations.
For health insurance coverage this authorization will expire twenty-four months from the date it is signed or upon termination of my insurance policy, whichever occurs first. For insurance coverage other
than health insurance, this authorization will expire twenty-four months from the date it is signed or upon expiration of my claim for benefits, whichever occurs first.
_______________________________________________________________
______________________________________________
Signature (Patient) or Personal Representative (if applicable) Printed Name (Patient)
_______________________________________________________________ ______________________________________________
Relationship of Personal Representative to Patient
Date
If authorization is supplied by a personal representative a description of the authority to act on behalf of the Insured must be included.
Please retain a copy for your personal records, or you may request a copy from our company.
/ /
( )
- -
Name Birth date
Name
Birth date
Name Birth dateName Birth date
Include a copy of your award or denial letter for any source in which one
has been received.
spouse & dependents:
Date of next Doctors appointment:
9. On what date did you last work?______________ Dates of total disability: From ______________ Thru ________________
On what date did you return to work? Part Time ________/________/________ Full Time ________/________/________
If not returned to work, when do you anticipate returning to work?___________________________
Admit Date: _______/_______/_______ Discharge Date: _______/_______/_______
