Get American Fidelity Long Term Disability Claim Form

Filling out the American Fidelity Long Term Disability Claim Form online can seem daunting, but with clear guidance, you can navigate it effectively. This step-by-step guide helps you understand each section of the form to ensure your submission is complete and accurate.

Follow the steps to complete your claim form online.

1. Press the ‘Get Form’ button to access the American Fidelity Long Term Disability Claim Form and open it in your document editor.
2. Begin by filling in your full name, including your last name, first name, and middle initial. Also, enter your maiden name if applicable.
3. Provide your account number and social security number, and add your date of birth.
4. Enter your telephone number, including area code, and your mailing address, which can be a P.O. Box or street address along with your city and zip code.
5. Document your occupation and complete the section regarding your treating physicians. Include their full names and addresses, attaching an additional list if necessary.
6. Specify the date you last worked, the duration of your total disability, and if applicable, the date you returned to work or anticipate returning.
7. If you were hospitalized, provide the names and addresses of the hospitals along with admission and discharge dates.
8. If you wish to set up direct deposit for your benefits, provide the name of your bank or credit union and include a voided check.
9. Indicate whether you would like federal taxes withheld from each benefit check, specifying the amount if 'Yes'.
10. State if you are receiving or eligible to receive any other income during your period of disability. Fill out the relevant fields regarding sick leave or disability coverage.
11. Sign and date the form, certifying that the information provided is true and correct.
12. Complete the employer's report of claim section, if applicable, including the employer's details and confirming the employee's employment status.
13. Ensure all sections are filled out completely before submitting the form. After reviewing, save the changes, download or print a copy for your records, and follow any submission instructions.

Complete your American Fidelity Long Term Disability Claim Form online today to ensure timely processing of your claim.