BN-708-0315(AFES)
Testing Benefits
Filing Instructions
Save Time and Paper - File Your Claim Online!
We offer two ways to file your testing expense claim: online or by mail/fax.
How to File Online:
1. Login to your secured Online Service Center (OSC) account at www.americandelity.com/MyAccount.
2. From the “My Claims” tab, click “File a Claim” to get started.
3. Conveniently upload the bill, receipt, or evidence which includes the name of the test and the date of service.
4. Follow step-by-step instructions to complete your online claim ling process.
5. Check the status of your claim by selecting the “My Claims” tab at the top of the screen!
How to File by Mail or Fax:
1. Complete the Statement of Insured.
2. Attach copies of the bill, receipt, or evidence which includes the name of the test and the date of service.
3. Mail the completed forms to American Fidelity at the address listed above.
4. If you wish to fax your completed forms, please fax to 800-818-3453.
Whether completing this claim online or with the below packet, all portions must be completed to avoid undue delay in process-
ing claimant’s request for benets. If you have any questions regarding completion of this form please call:
Toll Free: 800-662-1113
Local: 405-523-5025
Educational Services Division
Benets Department
P.O. Box 25160
Oklahoma City, Oklahoma 73125-0160
www.americandelity.com
REQUEST FOR
TESTING BENEFITS
BN-708-0315(AFES)
1. INSURED FULL NAME_______________________________________________________________ Account No. ______________________
(Please Print) (Last) (First) (M.I)
Date of Birth _____/_____/_____ Insured Social Sec. # __________-_______-__________ Telephone # (_____)______________
(MO) (Day) (YR)
2. Mailing Address _______________________________________________________________________________________________________
(Street) (City) (State) (Zip Code)
3. If claim is for dependent, give name of dependent________________________________________ Relationship_________________________
Date of Birth _____/_____/_____
(Mo) (Day) (YR)
STATEMENT OF INSURED
ATTN: AFES BENEFITS DEPT.
P.O. Box 25160
Oklahoma City, Oklahoma 73125
Toll Free: 1-800-662-1113
Fax: 1-800-818-3453
www.americandelity.com
Warning: Any person who knowingly and with intent to injure, defraud, or deceive an insurer les a statement of claim containing any false, incomplete, or misleading
information may be guilty of insurance fraud and subject to criminal and civil penalties.
California - For your protection, California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the
payment of a loss is guilty of a crime and may be subject to nes and connement in state prison.
AR, DC, LA, NJ, NM, TX, and WV - ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT
OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND
CONFINEMENT IN PRISON.
DE, ID, IN, MN, OH, and OK - WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, les a statement of claim containing any
false, incomplete, or misleading information is guilty of a felony.
Colorado - It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting
to defraud the company. Penalties may include imprisonment, nes, denial of insurance, and civil damages. Any insurance company or agent of an insurance company
who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the
department of regulatory agencies.
New Hampshire - Any person who, with a purpose to injure, defraud or deceive any insurance company, les a statement of claim containing any false, incomplete or
misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
Kentucky - Any person who knowingly and with intent to defraud any insurance company or other person les a statement of claim containing any materially false
information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Oregon - Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by ling a claim containing
a false statement as to any material fact, may be guilty of insurance fraud.
Pennsylvania - Any person who knowingly and with intent to defraud any insurance company or other person les an application for insurance or statement of claim
containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties.
Arizona - For your protection, Arizona law requires the following statement to appear on this form: Any person who knowingly
presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Florida - Any person who knowingly, and with intent to injure, defraud, or deceive any insurer les a statement of claim or an application containing any false, incomplete, or
misleading information is guilty of a felony of the third degree.
Hawaii - For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benet is a crime
punishable by nes or imprisonment, or both.
Alabama - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or who knowingly presents false information in
an application for insurance is guilty of a crime and may be subject to restitution nes or connement in prison, or any combination thereof.
Maryland - Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benet or who knowingly or willfully presents
false information in an application for insurance is guilty of a crime and may be subject to nes and connement in prison.
DIRECT DEPOSIT AUTHORIZATION
Please complete if you desire benets deposited directly into your bank account.
I authorize AFAC to initiate credit entries to my account at the depository named below. This authorization is to remain in force and effect until AFAC
receives written notication from me of its termination in such time and in such manner as to afford AFAC and the Depository opportunity to act on it.
This authorization applies to benets payable under all insurance policies held with AFAC.
Signature: ________________________________________________________________________________________________
NOTE: You must attach a voided check to begin direct deposit.
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