Download a Paper Claim Form

NOTE: Paper claim filing is not the fastest option.

File a claim through your online account or through our mobile app AFmobile^® to get your money faster!

Do you know what documentation you need? Learn What is Required to File a Claim

File a Claim

Search for the form you need, or click the name of the product to show the available forms.

Accident Insurance

- Accident Claim Form
  
  File a claim for accidental injury treatment or other accident insurance benefits.
- Accident Wellness Benefit Claim Form
  
  File a claim for your annual wellness benefit. NOTE: Use AFQuickClaims^® for faster claim processing. If you file online, no form is needed.
- Accident Insurance Disability Rider Claim Form
  
  If you purchased the optional Disability Rider with your accident policy, use this form to file a claim for disability.

Annuity Account

Death Benefit Form

File a claim to receive a death benefit for an annuitant.

Cancer Insurance

Cancer Claim Form

File a claim for cancer treatment, transportation and lodging, or other cancer insurance benefits.
Cancer Diagnostic Testing Benefit Claim Form

File a claim for your annual diagnostic testing benefit. NOTE: Use AFQuickClaims^® for faster claim processing. If you file online, no form is needed.

Critical Illness Insurance

Critical Illness Claim Form

File a claim for a heart attack, stroke, organ failure, or other critical illness insurance benefits.
Critical Illness Health Screening Benefit Claim Form

File a claim for your annual health screening benefit. NOTE: Use AFQuickClaims^® for faster claim processing. If you file online, no form is needed.
Critical Illness Attending Physician Statement

Download and print this form for your physician to complete regarding your critical illness diagnosis.

Dependent Care Account

Dependent Care Reimbursement Claim Form

File for a dependent care expense reimbursement. This form is also known as a Provider Acknowledgement Form.
Spanish Dependent Care Reimbursement Claim Form

File for a dependent care expense reimbursement. This form is also known as a Provider Acknowledgement Form.
FSA Authorization for Direct Deposit Form

Sign up to receive your HCFSA/DCA/HRA funds by direct deposit.

Disability Insurance

Disability Claim Form

File a claim to receive a portion of your income due to a covered disabling illness or injury, or other disability insurance benefits.
Disability Attending Physician Statement

This form is part of the full Disability Claim Form and is required to complete the claim process. You will complete the Statement of Insured on the first page, then have the physician in charge of your care complete the remaining pages. You may upload this to your online account or return it to American Fidelity via mail or fax.
Disability Employer Statement

This form is part of the full Disability Claim Form and is required to complete the claim process. Your employer must complete this form and upload through the employer online portal, or return to American Fidelity via mail or fax.
Extension of Disability Form

File a claim to extend an ongoing disability previously filed.
Disability Physician Expense Benefit Claim Form

File a claim for a doctor visit or other physician expenses you incurred while not on disability.
Disability Critical Illness Rider Claim Form

File a claim for a critical illness event if you purchased an optional Critical Illness Rider with your disability insurance policy.
Disability Routine Pregnancy Claim Form

File a claim to receive a portion of your income due to a routine childbirth without complications.
Waiver of Premium Benefit Form

If you have received disability payments for at least 90 days, you may apply for a waiver of premium. The physician who diagnosed your disability should complete this form.
Spousal Accident Only Disability Claim Form

File a claim for a spouse disabled due to an accident. This should be used if you purchased optional Spousal Accident Only Disability Rider with your disability insurance policy.

Gap Insurance

Gap Insurance Claim Form

File a claim for gap insurance benefits.

Healthcare FSAs & Health Reimbursement Arrangements

FSA Authorization for Direct Deposit Form

Sign up to receive your HCFSA/DCA/HRA funds by direct deposit.
Healthcare FSA & HRA Reimbursement Claim Form

File a reimbursement claim for an eligible out-of-pocket expense for your Healthcare FSA or HRA.
Spanish Healthcare FSA and HRA Reimbursement Claim Form

File a reimbursement claim for an eligible out-of-pocket expense for your Healthcare FSA or HRA.
Benefits Debit Card Substantiation Form

Use this form if your Benefits Debit Card was used to pay for an expense and you received a request from American Fidelity to substantiate (verify) the expense.
FSA Travel Log Expense Reimbursement Claim Form

File a reimbursement claim for medical travel/expenses for your Healthcare FSA.

Health Savings Accounts

HSA Distribution Request Form

File for an HSA reimbursement to pay yourself or a provider.
HSA Death Distribution Request Form

File for disbursement of HSA funds for a deceased account owner.

Hospital Indemnity Insurance

Hospital Indemnity Insurance Claim Form

File a claim for hospital indemnity insurance benefits.

Life Insurance

Life Insurance Claim Form

File a claim to receive a death benefit for an insured or annuitant.
Accidental Dismemberment and Paralysis Claim Form

File a claim to receive a benefit for accidental dismemberment or paralysis if you purchased an additional rider with your policy.
Accelerated Benefit for Critical Illness Claim Form

File a claim to receive a portion of a life insurance benefit in advance due to a covered critical illness
Life Benefit Waiver of Premium Form

If you become totally disabled and you purchased an optional Waiver of Premium Rider for your policy, complete this form to apply for a waiver of premium for your base policy.

Please note, all life insurance documentation must be submitted by mail or by fax.

Mail or fax health and disability insurance product claim forms to:

American Fidelity Assurance Company
Worksite Group Benefits Department
P.O. Box 25160
Oklahoma City, OK 73125
Fax: 800-818-3453

Mail or fax reimbursement claim forms to:

American Fidelity Assurance Company
Flex Account Administration
P.O. Box 161968
Altamonte Springs, FL 32716
Fax: 844-319-3668

Mail or fax life insurance claim forms to:

American Fidelity Assurance Company
Life and Annuity - Worksite
P.O. Box 25160
Oklahoma City, OK 73125
Fax: 800-818-3453

View Administration and Change Forms

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