Skip to main content
 

Claim Forms

Consider filing online to get your money faster!

Log in to your account

Add your claim information

We will review and process

Claim complete!

    • 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.

    • 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.

    • Extension of Spousal Accident Only Disability Claim Form

      To be used after you become disabled to claim benefits under the spousal accident only disability income rider.

  • Death Benefit Form

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

  • 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.

  • 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.

  • Critical Illness Attending Physician Statement

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

  • 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 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.

  • 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.

  • 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.

  • 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.

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

Need help?

If you have questions about your policy, log in to your online account or visit the support section.