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AMERICAN HERITAGE LIFE INSURANCE COMPANY 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE FLORIDA 32224-6687 APPEAL REQUEST FORM Please use this form to appeal a denial decision. Insured s Name Policy/Certificate No. Name of representative pursuing appeal if different from above Mailing Address Phone No. City State Type of Denial c Denied Claim Zip Code c Denied Service c Other What specific decision are you appealing Explain what you want our comp.

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