Fillable CLAIM FORM AND INSTRUCTIONS (Pensacola State College)

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CLAIM FORM AND INSTRUCTIONS (Pensacola State College)

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CLAIM FORM AND INSTRUCTIONS
If you have any questions regarding benefits available, or how to file your claim, or if you
would like to appeal any determination, please contact our Customer Care Center at
1-800-937-7039, 7:00 A.M. to 8:00 P.M. Eastern Standard Time
The
furnishing of this form, or its acceptance by the Company as proof, must not be construed as an admission of any
liability on the part of the Company, nor a waiver of any of the conditions of the insurance contract.
INSTRUCTIONS FOR FILING GROUP CLAIMS
Please check the appropriate box: Minimedical
Dental
Group Indemnity Medical (GIM)
• To avoid delays in processing please fill out the sections which apply to your specific claim.
• Include your policy number(s). To obtain your policy number call 1-800-937-7039.
• You may fax your claim to us at 1-866-424-8482. Please be assured that your claim will receive our immediate
attention. If you would like to receive your claim proceeds even faster, Allstate Benefits can automatically deposit
them into your bank account by completing and returning our ACH form (ABJ16661). This form can be found on our
website at www.allstatebenefits.com or electronically at www.allstatebenefits.com/mybenefits. Additional claim forms
are available on our website.
• You may mail your claim to: American Heritage Life Insurance Company
P.O. Box 853916
Richardson, Texas 75085
CERTIFICATEHOLDER
Employer Name (Company/Address): Occupation:
1. Certificateholder’s Name:
First Middle Last
E-mail:
Social Security Number:
Certificate Number:
Date of Birth:
Male Female
MO/DAY/YR
2. Home Number: Avg. Monthly Earnings:
PATIENT’S INFORMATION
3. Name:
First Middle Last
4. Date of Birth: Age: Social Security Number: Male Female
MO/DAY/YR
This person is your: (ex: self, wife, son, etc.)
Important: To avoid delay, please sign authorization below.
I authorize any physician, medical practitioner, hospital, clinic or other medical facility, Pharmacy Benefit Managers, insurance company, the Medical
Information Bureau or other organization, institution or person, that has records or knowledge of me or my health including my prescription medication
history to give to American Heritage Life Insurance Company (AHL) its subsidiaries or its reinsurers any information relating to my claim. I also authorize
AHL, or its reinsurers, to make a brief report of my health information to MIB, Inc. I understand that there is a possibility of redisclosure of any information
disclosed pursuant to this authorization and that information, once disclosed, may no longer be protected by federal rules governing privacy and
confidentiality, but may still be protected by state laws. A copy of this authorization is as valid as the original. This authorization applies to any
dependent on whom a claim is filed. This authorization is valid for a period of 24 months from the date signed. I understand that I may revoke this
authorization at any time by notifying AHL in writing of my desire to do so. I or my representative may receive a copy of this authorization by supplying
policy number(s) and Insured’s name in a written request to the company. (In MAINE – I understand that revocation of this authorization may be a basis
for denying insurance benefits. Failure to sign an authorization statement may impair the ability of a regulated insurance agency to evaluate claims and
may be a basis for denying a claim for benefits.)
Sign here: _______________________________________________ Date:_______________________ Check here if address is new
Claimant
Mailing Addres
s:_________________________________City:____________________State:_______ Zip: __________Telephone No:. ____________
Please submit a copy of your itemized bill with this form.
AB
J16673-5 1 of 3 (7/16)
ILLINOIS INTEREST STATEMENT: For contracts issued in and residents of Illinois, unless payment is made within
thirty-one (31) days from the date of receipt by the company of due proof of loss, interest shall accrue on the proceeds
payable because of the death of the insured, from date of death, at the rate of 10% on the total amount payable or the
face amount if payments are to made in installments until the total payment or the first installment is paid.
FRAUD WARNINGS BY STATE
NOTICE IN ALABAMA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
restitution fines or confinement in prison, or any combination thereof.
NOTICE IN ALASKA, KENTUCKY, LOUISIANA, MAINE, NEW JERSEY AND NEW MEXICO: Any person who
knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or
misleading information may be prosecuted under state law.
NOTICE IN 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.
NOTICE IN ARKANSAS: 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.
NOTICE IN CALIFORNIA: For your protection, California law requires the following to appear on this form. Any person
who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines
and confinement in state prison.
NOTICE IN 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, fines, 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.
NOTICE IN DELAWARE, IDAHO, INDIANA, MINNESOTA, AND OKLAHOMA: Any person who knowingly and with
intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading
information is guilty of a felony.
NOTICE IN DISTRICT OF COLUMBIA: FRAUD NOTICE: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the
applicant.
NOTICE IN FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the
third degree.
NOTICE IN MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss
or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and
may be subject to fines and confinement in prison.
NOTICE IN NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any insurance company,
files 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.
NOTICE IN NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person
files 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation.
NOTICE IN OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE IN OREGON: Any person who makes intentional misstatement that is material to the risk may be found guilty of
insurance fraud by a court of law.
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TICE IN PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other
person files 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.
NOTICE IN PUERTO RICO: Any person who knowingly and with the intention to defraud includes false information in an
application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit,
or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each
violation with a fine of no less than five thousands dollars ($5,000), not to exceed ten thousands dollars ($10,000); or
imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be
increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a
minimum of two (2) years.
NOTICE IN TENNESSEE AND WASHINGTON: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines
and denial of insurance benefits.
NOTICE IN TEXAS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a
crime and may be subject to fines and confinement in state prison.
NOTICE IN WEST VIRGINIA AND RHODE ISLAND: 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.
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CLAIM FORM AND INSTRUCTIONS (Pensacola State College)

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Completed 25 August 2020

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