Get American Fidelity Request For Continuing Disability Benefits Supplemental Form
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How to fill out the American Fidelity Request For Continuing Disability Benefits Supplemental Form online
This guide provides clear and step-by-step instructions on how to complete the American Fidelity Request For Continuing Disability Benefits Supplemental Form online. Whether you are familiar with online forms or new to the process, this guide will support you in successfully submitting your information.
Follow the steps to complete the supplemental form online.
- Click ‘Get Form’ button to obtain the form and open it in an online editor.
- Complete the statement of insured section. Provide your full name, social security number, and contact details. Ensure that all information matches your records.
- Indicate whether you are currently under the care of a physician. If yes, fill in the physician’s name and address.
- Answer whether you have been hospital confined since the last report. If so, include the dates and the hospital's name and address.
- Provide details of any treatment received at the doctor's office since the last report.
- State your current employment status. Indicate if you are working, when you started, or describe your activities if you are not.
- Indicate your expected date to return to work and note any other illnesses or accidents that have occurred since the last report.
- Respond to questions regarding employment termination and tax withholding preferences from benefit checks.
- Identify other income sources and specify the amount you receive or may be entitled to during your disability.
- Provide authorization for direct deposit if applicable, by filling in your bank or credit union details and attaching a voided check.
- Authorize the disclosure of your protected health information. Carefully read this section and sign where required.
- Complete the attending physician’s statement section if requested. Submit all required information from your healthcare provider.
- Once you have filled out the form completely and checked for accuracy, save your changes, and utilize options to download, print, or share the form.
Start filling out your documents online today and ensure your benefits are processed efficiently.
American Fidelity accident insurance provides coverage for injuries resulting from unexpected accidents. This can include hospital stays, medical treatments, and other expenses related to your recovery. To make the most of your benefits, consider using the American Fidelity Request For Continuing Disability Benefits Supplemental Form to clarify your circumstances and claim support.
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