Administrative and Change Forms

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Account Administration

- Change of Beneficiary
  
  Complete this form to change or add a beneficiary to an insurance policy.
- Change of Ownership
  
  Complete this form to 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.
- Delete Dependents
  
  Complete this form to remove dependents from your insurance coverage.
- Direct Deposit Authorization - FSA/HRA
  
  Complete this form to sign up for direct deposit for your Healthcare Flexible Spending Account, Dependent Care Account, or Health Reimbursement Arrangement. For insurance policies, please complete the Direct Deposit Authorization - Insurance. You may also complete this request by logging in to your online account.
- Direct Deposit Authorization - Insurance
  
  Complete this form to sign up for direct deposit for your insurance policies. For reimbursement accounts, complete the Direct Deposit Authorization - FSA/HRA. You may also complete this request by logging in to your online account.
- Duplicate Policy Request
  
  You may access your policy documents anytime by logging in to your online account and selecting the My Benefits tab. Complete this form only if you choose not to view and print your document through the Online Service Center.
- Friends/Family Authorization to Disclose Information Including PHI
  
  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 or to speak to American Fidelity on your behalf.
- FSA/HRA Additional Card Request
  
  Complete this form to request an additional Benefits Debit Card for your Healthcare Flexible Spending Account or Health Reimbursement Arrangement. For faster service, you may also complete a card request online.
- Keep My Coverage Electronic Funds Transfer
  
  If you are leaving your employer or retiring and wish to move to a direct bill, complete this form to sign up for Electronic Funds Transfer (EFT). NOTE: You must contact the Conservation Department about keeping your policies before completing this form.
- Provider/Holder Authorization to Disclose Information Including PHI
  
  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.
- Spousal Waiver of Benefits
  
  In some 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.

Annuities

Contact Information Change

Address Change

Download this form to submit a change of address for your insurance policies. You may also complete this request by logging in to your online account.
Name Change

Download this form to submit a name change for your insurance policies.

Health Savings Account Administration

Section 125 Administration

55% Average Benefits Test for Dependent Daycare 2019

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.
25% Key Employee Non-Discrimination Worksheet 2019

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.
55% Average Benefits Test for Dependent Daycare 2018

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.
25% Key Employee Non-Discrimination Worksheet 2018

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.
Section 125 Plan Administration Guide

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.
Employer Medical Expense Reimbursement Policy Provisions

This guide requires a password, provided to employer customers in orientation materials. Please contact us if you need assistance.
Calculation 79 Worksheet

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

Administrative and Change Forms

Change of Beneficiary

Change of Ownership

Delete Dependents

Direct Deposit Authorization - FSA/HRA

Direct Deposit Authorization - Insurance

Duplicate Policy Request

Friends/Family Authorization to Disclose Information Including PHI

FSA/HRA Additional Card Request

Keep My Coverage Electronic Funds Transfer

Provider/Holder Authorization to Disclose Information Including PHI

Spousal Waiver of Benefits

Annuities Change of Beneficiary Form

Annuities Contribution Bank Draft Authorization (RIRA, TIRA, ATA)

Annuities Loan Bank Draft Authorization

Annuities Spousal Waiver of Benefits

Address Change

Name Change

HSA Beneficiary and Spousal Consent

HSA Beneficiary Designation

HSA Additional Debit Card Request

HSA Contribution

HSA Distribution Request

HSA Investment Fund Listing

HSA Investment Election

HSA Investment Change

HSA Information Change

HSA Rollover/Transfer

IRA to HSA Transfer

IRS Form 1099 SA

IRS Form 1099 SA Instructions

IRS Form 5498 SA

IRS Form 8889

55% Average Benefits Test for Dependent Daycare 2019

25% Key Employee Non-Discrimination Worksheet 2019

55% Average Benefits Test for Dependent Daycare 2018

25% Key Employee Non-Discrimination Worksheet 2018

Section 125 Plan Administration Guide

Employer Medical Expense Reimbursement Policy Provisions

Calculation 79 Worksheet