Forms

Need to file a claim? Update your address? Get a release for your physician or family members?

You’re in the right place. Most actions below can be completed quickly through your online account or AFmobile®. 

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    • Direct Deposit Authorization- FSA/HRA

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

    • Direct Deposit Authorization- Insurance

      Sign up for direct deposit for your insurance benefits.

    • Direct Deposit Authorization- Annuity Account

      Sign up for direct deposit for your annuity account.

       

  • Address Change

    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.

  • Beneficiary Change

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

     

  • Delete Dependents

    Remove dependents from your insurance coverage.

     

  • Name Change

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

     

  • Ownership Change

    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.

     

  • 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.

     

  • Provider/Holder Authorization to Obtain 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.

     

  • Accident Claim Form

    File a claim for accidental injury treatment or other accident insurance benefits.

  • Accident Wellness and Screening Benefit 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.

  • 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.

  • 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.

     

  • Annuities Change of Beneficiary Form

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

     

  • Annuities Name Change Form

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

     

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

    Complete this form to authorize bank draft contributions to your annuity account.

     

  • Annuities Loan Bank Draft Authorization

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

     

  • Annuities Spousal Waiver of Benefits

    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.

     

  • 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.

  • Formulario en español para reclamación por cáncer

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

  • 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

    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.

     

  • Dependent Care Reimbursement Claim Form

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

  • Formulario en español para reclamación de reembolso por atención de dependiente

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

  • 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.

  • Formulario para reclamo de discapacidad

    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.

     

  • Disability Attending Physician Statement

    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.

     

  • Disability Employer Statement

    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.

     

  • Extension of Disability Form

    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. 

     

  • Formulario para extensión de discapacidad

    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.

     

  • 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.

  • Formulario para reclamo de discapacidad por embarazo

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

     

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

     

  • Spousal Disability Claim Form

    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.

  • Spousal Disability Claim Extension Form

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

     

  • PFML Rider Claim Form

    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.

     

  • FML Rider Form - CA Only

    If you have the Family Medical Limited Benefit Rider with your disability insurance policy, you can file a claim to receive a portion of your income due to an approved medical leave from your employer. However, this option does not cover an approved leave for your own serious health condition.

     

     

  • Healthcare FSA & HRA Reimbursement Claim Form

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

  • Formulario en español para reclamación de reembolso por FSA y HRA para atención médica

    Presente una reclamación para el reembolso de un gasto de su bolsillo elegible para su FSA o HRA para atención médica.

  • 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.

     

  • Additional Card Request

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

  • Additional Card Request

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

  • HSA Beneficiary and Spousal Consent

    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.

     

  • HSA Beneficiary Designation

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

     

  • HSA Contribution

    Contribute funds to your Health Savings Account. 

  • HSA Death Distribution Request Form

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

     

  • HSA Distribution Request

    Withdraw funds from your Health Savings Account.

  • HSA Rollover/Transfer

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

     

  • IRA to HSA Transfer

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

     

  • Life Insurance Claim Form

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

     

  • 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.

     

  • Accelerated Benefit for Long-Term Illness Claim Form

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

     

  • Oregon Paid Family and Medical Leave Insurance (PFMLI) Request Form

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

  • Oregon Health Care Provider Certification Form

    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.

     

  • Employer's Report of Claim Form

    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.

     

  • Colorado Paid Family and Medical Leave Insurance (PFMLI) Request Form

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

  • Colorado Health Care Provider Certification Form

    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.

     

  • 55% Average Benefits Test for Dependent Daycare 2024

    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 2024

    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.

     

  • 55% Average Benefits Test for Dependent Daycare 2023

    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 2023

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

     

  • 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.

     

  • Duplicate Policy Request

    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.

Mail-In Claim Form Information

Health and Disability Insurance Product

Mail or fax claim forms to:

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

Reimbursement 

Mail or fax claim forms to:

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

Life Insurance

Mail or fax claim forms to:

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

Paid Family and Medical Leave Insurance (PFMLI)

Mail or fax request forms to:

American Fidelity Assurance Company
Worksite Group Benefits Department
P.O. Box 248929
Oklahoma City, OK 73124
Fax: 855-651-1294

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