Customer
Forms

Sign up for direct deposit for your Healthcare Flexible Spending Account, Dependent Care Account, or Health Reimbursement Arrangement. 

Sign up for direct deposit for your insurance benefits.

Sign up for direct deposit for your life insurance benefits.

Sign up for direct deposit for your annuity account.

Submit a change of address for your insurance policies or reimbursement accounts. You may also change your address online at any time by visiting your Profile through your online account.

Complete this form to change the name on your annuity account.

Change or add a beneficiary to an insurance policy. For Annuity accounts, please use the Annuities Change of Beneficiary Form instead.

Remove dependents from your insurance coverage.

Submit a name change for your insurance policies or reimbursement accounts.

Transfer the ownership of an insurance policy. This form is typically used for the purpose of changing ownership from a parent to a child, or from an insured to a Power of Attorney.

Complete this form if you would like to authorize somebody (such as a friend or family member) to obtain information about you from American Fidelity. This does not apply to annuity accounts.

Complete this form to authorize American Fidelity to obtain information about you from your doctor, employer, or others in order to process benefits, confirm policy information, or other related information.

File a claim for accident insurance injury treatment or other covered accident using this accident claim form. 

File a claim for your annual Wellness or Screening Benefit^*.

^{*Wellness Benefit: Only available on the AO-03 Series Accident Insurance plan. Screening Benefit: Only available on the AO22 Series Accident Insurance plan. Wellness and Screening Benefits are not available in all states.}

If you purchased the optional Disability Rider with your accident policy, use this form to file a claim for disability.

To be used after your spouse becomes disabled to claim benefits under the spousal accident only disability income rider. 

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

Complete this form to change the beneficiary for your annuity account.

Complete this form to change the name on your annuity account.

Complete this form to authorize automatic bank draft payments for your annuity account loan.

In some states, if you wish to designate someone other than your spouse as the primary beneficiary of a plan, your spouse must sign this waiver of benefits.

File a claim for cancer treatment, transportation and lodging, or other cancer insurance benefits.

File a claim for your annual diagnostic testing benefit.

Presente una reclamación por tratamiento para el cáncer, transporte y alojamiento, u otros beneficios del seguro por cáncer.

File a claim for a heart attack, stroke, organ failure, or other critical illness insurance benefits.

File a claim for your annual health screening benefit.

This form is part of the full Critical Illness Claim Form above and is required to complete the claim process. You must have the physician in charge of your care complete this page. You may upload this to your online account by selecting the Additional Documentation button.

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

Presente para el reembolso de un gasto por atención de dependiente. Este formulario también se conoce como Formulario de reconocimiento del proveedor.

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

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

Presente un reclamo para recibir una parte de sus ingresos debido a una enfermedad o lesión discapacitante u otros beneficios cubiertos bajo su seguro por discapacidad.

This form is part of the full Disability Claim Form above and is required to complete the claim process. You must have the physician in charge of your care complete this page. You may upload this to your online account by selecting the Additional Documentation button.

This form is part of the full Disability Claim Form and is required to complete the claim process. Your employer can complete this form through their online account. Or, you may print this version and have your employer return it to American Fidelity via mail or fax.

File a claim to extend an ongoing disability previously filed. Once completed, you may upload this through your online account by selecting the Additional Documentation button. 

Presente un reclamo para extender una constante discapacidad previamente presentada. Una vez completado, puede subirlo a través de su cuenta en línea seleccionando el botón de Documentación Adicional.

File a claim for a doctor visit or other physician expenses you incurred while not on disability.

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

File a claim to receive a portion of your income due to a routine childbirth without complications.

Presente un reclamo para recibir una parte de sus ingresos debido a un embarazo sin complicaciones.

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. Once completed, you may upload this through your online account by selecting the Additional Documentation button. 

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

File a claim to extend a previously filed spousal accident only disability claim.

If you have the Paid Family Leave Limited Benefit Rider with your disability insurance policy, you can file a claim to receive a portion of your income due to an approved leave of absence. We will pay a benefit if your employer has approved your leave of absence for one of the qualifying reasons, which include bonding, family care giving, or a qualifying exigency.

If you have the Paid Family Leave Limited Benefit Rider with your disability insurance policy, you can file a claim to receive a portion of your income due to an approved leave of absence. We will pay a benefit if your employer has approved your leave of absence for one of the qualifying reasons, which include bonding, family care giving, or a qualifying exigency.

Si su póliza de seguro por discapacidad incluye la cláusula de beneficios limitados por licencia médica familiar, puede presentar una reclamación para recibir una parte de sus ingresos debido a una licencia médica aprobada de su empleador. Sin embargo, esta opción no cubre una licencia aprobada debido a sus propias afecciones de salud graves.

File a claim for gap insurance benefits.

File a reimbursement claim for an eligible out-of-pocket expense for your Healthcare FSA or HRA.

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.

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

Request an additional Benefits Debit Card for your reimbursement account. You can do this anytime online or through AFmobile on the Cards menu.

Request an additional Benefits Debit Card for your reimbursement account. You can do this anytime online or through AFmobile on the Cards menu.

In some states, if you wish to designate someone other than your spouse as the primary beneficiary of a plan, your spouse must sign this waiver of benefits.

Designate, revoke, or change a beneficiary for your Health Savings Account.

Contribute funds to your Health Savings Account. 

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

Withdraw funds from your Health Savings Account.

Rollover or transfer your Health Savings Account funds to or from a different provider.

Transfer funds from your Individual Retirement Account (IRA) to your American Fidelity HSA.

File a claim for hospital indemnity insurance benefits.

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

File a claim to receive a benefit for accidental dismemberment or paralysis if you purchased an additional rider with your policy.

File a claim to receive a portion of a life insurance benefit in advance due to a covered critical illness.

File a claim to receive a portion of a life insurance benefit in advance due to a covered long-term illness.

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.

Use this form to file a paid leave request to receive PFMLI benefits through American Fidelity’s equivalent plan for the state of Oregon.

To complete a leave request, this form is necessary. The treating health care provider responsible for your care must complete this page and return it to you. You can then upload it through your online account.

To complete a leave request, this form is necessary. Your employer can fill it out via their online account. Alternatively, you can print it and have your employer send it to American Fidelity via mail or fax.

Use this form to file a paid leave request to receive PFMLI benefits through American Fidelity’s equivalent plan for the state of Colorado.

To complete a leave request, this form is necessary. The treating health care provider responsible for your care must complete this page and return it to you. You can then upload it through your online account.

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance. 

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.

In some states, such as community property states, if you do not designate your spouse as the primary beneficiary of a policy, your spouse must sign this waiver of benefits if you wish to name someone else as the beneficiary.

Request a printed version of your policy document. You may access your policy documents anytime by logging in to your online account and selecting your policy name in the Benefits widget. This does not apply to annuity accounts. Please contact us to request a duplicate policy for annuity accounts.