Claim Forms
Consider filing online to get your money faster!
Accident Insurance
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Accident Claim Form
File a claim for accidental injury treatment or other accident insurance benefits.
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Accident Wellness Benefit Claim Form
File a claim for your annual wellness benefit.
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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.
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Annuity Account
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Death Benefit Form
File a claim to receive a death benefit for an annuitant.
Cancer Insurance
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Cancer Claim Form
File a claim for cancer treatment, transportation and lodging, or other cancer insurance benefits.
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Cancer Diagnostic Testing Benefit Claim Form
File a claim for your annual diagnostic testing benefit.
Critical Illness Insurance
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Critical Illness Claim Form
File a claim for a heart attack, stroke, organ failure, or other critical illness insurance benefits.
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Critical Illness Health Screening Benefit Claim Form
File a claim for your annual health screening benefit.
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Critical Illness Attending Physician Statement
Download and print this form for your physician to complete regarding your critical illness diagnosis.
Dependent Care Account
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Dependent Care Reimbursement Claim Form
File for a dependent care expense reimbursement. This form is also known as a Provider Acknowledgement Form.
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Spanish Dependent Care Reimbursement Claim Form
File for a dependent care expense reimbursement. This form is also known as a Provider Acknowledgement Form.
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FSA Authorization for Direct Deposit Form
Sign up to receive your HCFSA/DCA/HRA funds by direct deposit.
Disability Insurance
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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.
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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.
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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.
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Extension of Disability Form
File a claim to extend an ongoing disability previously filed.
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Disability Physician Expense Benefit Claim Form
File a claim for a doctor visit or other physician expenses you incurred while not on disability.
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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.
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Disability Routine Pregnancy Claim Form
File a claim to receive a portion of your income due to a routine childbirth without complications.
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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.
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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
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Gap Insurance Claim Form
File a claim for gap insurance benefits.
Healthcare FSAs & Health Reimbursement Arrangements
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FSA Authorization for Direct Deposit Form
Sign up to receive your HCFSA/DCA/HRA funds by direct deposit.
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Healthcare FSA & HRA Reimbursement Claim Form
File a reimbursement claim for an eligible out-of-pocket expense for your Healthcare FSA or HRA.
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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.
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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.
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FSA Travel Log Expense Reimbursement Claim Form
File a reimbursement claim for medical travel/expenses for your Healthcare FSA.
Health Savings Accounts
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HSA Distribution Request Form
File for an HSA reimbursement to pay yourself or a provider.
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HSA Death Distribution Request Form
File for disbursement of HSA funds for a deceased account owner.
Hospital Indemnity Insurance
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Hospital Indemnity Insurance Claim Form
File a claim for hospital indemnity insurance benefits.
Life Insurance
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Life Insurance Claim Form
File a claim to receive a death benefit for an insured or annuitant.
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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.
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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
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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.