Fillable Disability Insurance Claim Packet Disability Claim Filing Instructions (Pensacola State College)

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Disability Insurance Claim Packet Disability Claim Filing Instructions (Pensacola State College)

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Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
Disability Insurance Claim Packet
Disability Claim Filing Instructions
INSTRUCTIONS – PLEASE READ CAREFULLY AND SUBMIT ALL REQUIRED INFORMATION
We offer four options for filing a disability claim:
1. Call our disability claims team at 1-855-517-6365 (Spanish available). A claims representative is available to assist you between
8 am and 6 pm ET, Monday through Friday. When calling, you should have the following information readily available: Employee's
personal information (including social security number), Employer's Name, Group policyholder number, Employee's hire date,
contact information for doctors, hospitals or clinics treating the Employee and dates of treatment. You should also have
information regarding a worker's compensation or state disability claim if one has been or will be filed.
If you do not wish to call the disability claims team, please complete the following forms and send the forms and supporting
documentation to us by:
2. Email to Disability.claims@oneamerica.com;
3. Fax to 1-844-287-9499; or
4. Mail to American United Life Insurance Company, P.O. Box 9060, Portland, ME 04104.
If you have any questions when completing the claim forms, please call a claims representative at 1-855-517-6365.
All questions should be answered fully and accurately before a decision on benefit entitlement can be made. All forms should be
completed as follows:
Employee's Statement for Disability Insurance Claim Form – The Employee should complete this form.
Policyholder’s Statement for Disability Insurance Claim Form – The policyholder (Employer) should complete in full and
submit the following information:
• Enrollment forms, requests for increase or decrease in coverage amount, approval of Evidence of Insurability, and/or
enrollment information from the policyholder's electronic enrollment system.
• Most recent W2 if salary is based on W2.
• Employee's current job description.
Attending Physician Statement for Disability Claim – The primary medical provider treating the Employee for the conditions
related to this injury or sickness should complete this form. A list of current medications should be attached to the form.
Authorization for Release of Information – The Employee should read, sign and date this form. This form is required for us to
obtain additional documentation to support this claim.
Direct Deposit Authorization Agreement – This form should be completed by the Employee if he/she wishes to have disability
payments deposited into his/her bank account. Banking information specified on the form should be attached.
It is the responsibility of you and your employer to inform us of any scheduled or actual return to work date as soon as possible.
If an overpayment should occur on your claim, the amount of the overpayment must be returned to us.
G-28203 12/19/18
Page 1 of 2 G-31148 (Packet) 11/8/18
Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
Employee's Statement for
Disability Insurance Claim Form
Claim is being filed for:
Short-Term Disability
Long-Term Disability
To Be Completed By Employee (please print)
If the claim form is not completed in full, determination of benefits will be delayed until all required information has been received.
Write "NA" in non-applicable sections.
1. Employee's Name 2. Social Security Number
Street/Box/Apt. 3. Phone Number
City, State, Zip 4. Email Address
5. Height 6. Weight 7. Gender 8. Date of Birth
Male Female
9. Employer's Name 10. Employer's Address
11. Employer's Phone Number City, State, Zip
12. Occupation 13. List Occupation Duties Hourly Salaried Executive
Management Union
14. Date of accident or first symptoms 15. Date Last Worked 16. Are you unable to work due to (check one)
Accidental Injury Illness Pregnancy
17. Date you returned to work 18. If you have not returned to work, date you expect to return
Full-Time Part-Time Full-Time Part-Time
19. Describe in detail, when, where and how accidental injury occurred, or nature of disability and first symptoms
20. Is your accidental injury or illness related to your occupation? 21. Have you filed a Worker's Compensation Claim?
Yes No Yes No If no, do you intend to? Yes No
If yes, explain: If no, explain:
22. When were you first treated for your accidental injury or illness?
Hospital Address/Phone Number Date(s)
Doctor Address/Phone Number Date(s)
23. Have you ever had same or similar condition in the past?
Yes No If yes, list name and address of Hospital/Doctor below.
Hospital Address/Phone Number Date(s)
Doctor Address/Phone Number Date(s)
Page 2 of 2 G-31148 (Packet) 11/8/18
Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
Employee's Statement for
Disability Insurance Claim Form
Claim is being filed for:
Short-Term Disability
Long-Term Disability
Employee Name Employer Name and Policy Number
24. Are you receiving any of the following? (check each benefit you are receiving)
Amount Begin Date End Date Amount Begin Date End Date
Worker's $ Unemployment $
Compensation
Social Security/ $ Other $
Veteran's Administration (Retirement Income)
State Disability $ Auto Insurance $
Wage Replacement*
Vacation/Sick/PTO $ *If yes, give name and address of Insurer below.
Insurer Name(s) Address
25. Marital Status 26. If Married, Spouse Name and SSN 27. Spouse Date of Birth
Single Married Divorced Widowed
28. Is Spouse Employed? 29. List children under age 25 (Names and Dates of Birth)
Yes No
Tax Withholding
If benefits are approved, do you want federal income taxes withheld from your payments? Yes No
If yes, complete the following:
I request federal income tax withholding from my sick pay payments. I want the following amount withheld from each payment:
$ Weekly (short-term disability) Monthly (long-term disability)
The minimum amount we can withhold is $20 per week from weekly payments or $88 per month for monthly payments. Amounts
entered must be in whole dollar amounts. (For example, $35 not $34.50) Tax withholding cannot reduce the net amount of each sick
pay payment to less than $10.00. This designation will remain in effect until you change or revoke it. You may change or revoke
Federal Tax Withholding by providing an updated IRS W-4S form to us. Please refer to IRS form W-4S for additional information. If
you elect not to have federal income tax withheld, you remain liable to pay your taxes for the taxable portion of these payments.
Signature
The undersigned represents any information or documents provided to American United Life Insurance Company
®
(AUL) by the
undersigned prior to and after the date of the application for insurance and the facts and other matters contained in the foregoing
are true and accurate to the best of the undersigned’s knowledge and belief. The undersigned understands and agrees that any
insurance coverage or benefits are contingent upon any statements made to AUL or its third party administrator as being completed
and correct. The undersigned acknowledges reading and understanding the state specific fraud statements and the Discretionary
Authority statements on the following pages.
Employee Name (please print) Date
Employee Signature
X
Page 1 of 2 G-31147 (Packet) 11/8/18
Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
Policyholder's Statement for
Disability Insurance Claim Form
Claim is being filed for: Short-Term Disability
Long-Term Disability
Maternity
To Be Completed By Employer (please print)
If the claim form is not completed in full, determination of benefits will be delayed until all required information has been received.
Write "NA" in non-applicable sections.
1. Employee's Name 2. Social Security Number
Street/Box/Apt. 3. Date of Birth
City, State, Zip Employee’s Phone Number 4. Regularly Scheduled Hours Per Week
5. Date of Hire 6. Employee's Short-Term 7. Employee's Long-Term 8. Occupation
Disability Effective Date Disability Effective Date
9. Policy Number 10. Policy Class 11. Work Location
12. Check Employee's Work Schedule
Full-Time Part-Time Exempt Non-Exempt Seasonal
13. Check Regular Workdays
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
14. If not at work when disability began, check status and provide date 15. How was employee paid? (check frequency and types)
Terminated Leave of Absence Laid Off Frequency: Weekly Bi-Weekly
Sick Leave Vacation Resigned Semi-Monthly Monthly
Other: Date: Type(s): Hourly Bonus
Salary Commission
16. Salary Prior to Date Last Worked 17. Date Last Salary Increase 19. New York DBL
Base Weekly Wages $ Yes No
W-2 Earnings $ 18. Employee Work Schedule at Time Last Worked New Jersey TDB
Overtime $ Days per week Yes No
Commissions $ Hours per week (If yes, complete reverse side)
Bonus $
Hourly Rate $
20. Date Last Worked 21. Hours Worked That Day 22. Has Employee Returned to Work? Full-Time
Yes No If yes, Date: Part-Time
23. Date Paid Through
For: Salary Continuation Vacation Accrued Sick Pay PTO
24. Does your company have a rehire or return to work policy for disabled employees?
Yes No What is the name of the person we should contact if we identify a return to work option?
25. Name/Address of the employee's medical insurance carrier (provide policy or ID No.)
Page 2 of 2 G-31147 (Packet) 11/8/18
Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
Policyholder's Statement for
Disability Insurance Claim Form
Claim is being filed for: Short-Term Disability
Long-Term Disability
Maternity
26. Employee is Eligible for: Yes No If yes, Weekly or Wk Mo Provider Name/Address Date Benefits Date Benefits
Monthly Amount Begin End
Salary Continuation $
Disability Pension $
Retirement Pension $
State Disability $
Unemployment $
Social Security $
Workers' Compensation $
Has Workers' Comp.
claim been filed? If Worker's Compensation has been denied, submit copy of denial with this claim.
27. Are the Employee's current wages exempt from FICA?
Yes No
Please complete the below premium questions. If not fully completed, this claim will be taxed at 100%.
28. Percentage of Employee/Employer contributions to premium for this disability coverage (as of policy year of disability):
Short-Term Disability
Employee: 100% Other %
Are Employee Contributions: Pre-Tax Deduction Post-Tax Deduction
Employer: 100% Other %
Long-Term Disability
Employee: 100% Other % Are Employee Contributions: Pre-Tax Deduction Post-Tax Deduction
Employer: 100% Other %
If 100% Employer paid, do you gross up the Employee's W-2 with premium on an after tax basis? Yes No
If yes, applies to: Short-Term Disability Long-Term Disability
Or, are premiums paid under a 2004-55 plan? Yes No
If yes, applies to: Short-Term Disability Long-Term Disability
The undersigned represents any information or documents provided to American United Life Insurance Company
®
(AUL) by the
undersigned prior to and after the date of the application for insurance and the facts and other matters contained in the foregoing
are true and accurate to the best of the undersigned’s knowledge and belief. The undersigned understands and agrees that any
insurance coverage or benefits are contingent upon any statements made to AUL or its third party administrator as being completed
and correct. The undersigned acknowledges reading and understanding the state specific fraud statements and the Discretionary
Authority statements on the following pages.
Employer's Name (please print) Phone Number
Street Address City State Zip
Employer's Signature (The above statements are true and complete to the best Date
of my knowledge)
Email
X
A Job Description is required if employee is out of work more than 6 weeks.
Page 1 of 2 G-31146 (Packet) 10/10/18
Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
Attending Physician Statement
for Disability Claim
To Be Completed By Physician
Patient Name Employer's Name
Height Weight Blood Pressure (last visit) Date of Birth
1. Patient is/was unable to work due to (check one)
Injury Illness Pregnancy
2. Diagnosis (include complications and ICD 9 or ICD 10)
For Pregnancy, Complete Items 3-6 (If Normal Pregnancy, only complete 3-6 and skip to item 25)
3. Last Menstrual Period (LMP) Date 4. Expected Date of Delivery 5. Date First Treated 6. Date Last Treated
For All Conditions Except Normal Pregnancy, Complete The Following Items
7. Date symptoms first appeared or 8. Date patient was advised to stop working 9. Is condition due to injury or illness
accident happened? arising out of patient's employment?
Yes No
10. Has patient ever had same or similar condition? If yes, state when and describe
Yes No
11. Date of First Visit 12. Date Last Visit 13. Frequency of Visits
14. Objective Findings (x-rays, EKG's, lab data and clinical findings) 15. Subjective Symptoms
16. Nature of Treatment (surgery, medications, etc.) Provide medication dosage and frequency
17. Names and addresses of patient's other physicians 18. Name of physician you referred this patient to
19. Has patient been hospitalized If yes, give name and address
Yes No From to
20. Restrictions you have placed on patient 21. Limitations of Patient
(what the patient SHOULD NOT do) (what the patient IS INCAPABLE of doing)
22. Mental Impairment (if applicable) Provide 5 AXIS Diagnosis
I IV
II V
III
23. If this is a cardiac condition, what is the functional capacity? Class 1 - No Limitation Class 3 - Marked Limitation
(American Heart Association) Class 2 - Slight Limitation Class 4 - Complete Limitation
24. Has maximum medical improvement been achieved? If no, when do you expect a fundamental change?
Yes No 1-2 weeks 3-4 weeks 5-6 weeks More than 6 weeks
Page 2 of 2 G-31146 (Packet) 10/10/18
Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
Attending Physician Statement
for Disability Claim
Employee Name Employer Name and Policy Number
25. If employer is able to accommodate patient's limitations and
restrictions, is patient able to return to work? If yes, what date could employment begin?
Yes No
26. Current Functional Ability
a. In an 8 hour work day, what is the maximum number of hours your patient could perform each of these levels of activity?
(please indicate appropriate number of hours):
Hrs. Sedentary Work Activity 10 lbs. maximum lifting or carrying articles. Walking/standing on occasion.
Sitting 6 to 8 hours.
Hrs. Light Work Activity 20 lbs. maximum lifting, carrying 10 lbs. articles frequently, most jobs involving
standing with a degree of pushing and pulling. Standing 6 to 8 hours.
Hrs. Medium Work Activity 50 lbs. maximum lifting with frequent lifting/carrying of up to 25 lbs.
Frequent walking and standing.
Hrs. Heavy Work Activity 100 lbs. maximum lifting, frequent lifting/carrying of up to 50 lbs.
Frequent walking and standing.
The undersigned Medical Provider represents and warrants any information or documents provided to American United Life
Insurance Company
®
(AUL) by this Medical Provider and the facts and other matters contained in the foregoing are true and
accurate to the best of the undersigned’s knowledge and belief. The undersigned Medical Provider acknowledges reading and
understanding the state specific fraud statements on the following pages.
Attending Physician’s Signature Date
Medical Provider’s Name (please print)
Degree/Specialty
Telephone Number Fax Number Tax ID Number
Office Address
City or Town State Zip Code
Page 1 of 1 G-31012 (Disability) 10/10/18
Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
Fraud Notices
• Fraud Warnings (For use in AL, AR, DC, LA, 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 may be guilty of a crime and may be subject to fines and confinement in prison.
• Alaska: A 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.
• 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.
• 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
fines and confinement in state prison.
• 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 or 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.
• Delaware, Idaho, Indiana, Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive
any insurer, makes any statement of claim for the proceeds of an insurance policy containing any false,
incomplete or misleading information is guilty of a felony.
• 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.
• Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a
statement of a claim or an application for insurance 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.
• Maine, Tennessee, 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 may include imprisonment, fines
or a denial of insurance benefits.
• Maryland, Rhode Island: 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.
• Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is
guilty of a crime.
• New Hampshire, Ohio: 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.
• New Jersey: Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
• Oregon: Any person who makes an intentional misstatement that is material to the risk may be found guilty of
insurance fraud by a court of law.
• Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or any 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 a person to criminal and civil penalties.
• Virginia: 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.
G-25673 (Disability) 10/12/18
Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
Discretionary Authority
The following discretionary authority rights shall apply to all policies except the states below:
DISCRETIONARY AUTHORITY: Benefits under the policy will be paid only if American United Life Insurance
Company
®
(AUL) (or its third party administrator) decides in its discretion the claimant is entitled to them.
Except for the functions the policy explicitly reserves to the Participating Unit or Trustee, AUL (or its third party
administrator) reserves the right to: 1) manage the policy and administer claims under it; and 2) interpret the
provisions and resolve any questions arising under it.
AUL’s (or its third party administrator’s) authority includes, but is not limited to, the right to:
1) establish and enforce procedures for administering the policy and claims under it;
2) determine participants’ eligibility for coverage and entitlement to benefits;
3) determine what information it reasonably requires to make such decisions; and
4) resolve all matters when a claim review is requested.
Any decision that AUL (or its third party administrator) makes, in the exercise of its authority, will be conclusive
and final subject to any rights under applicable laws such as the Employee Retirement Income Security Act
(ERISA). This provision applies only where the interpretation of the policy is governed by ERISA. AUL may
delegate some or all of its rights under this Discretionary Authority provision to another person or entity, and AUL
hereby desires to share with and delegate rights under this provision to its designated third party administrator.
Such discretionary authority shall not apply in the following states:
1. Arkansas
2. Alaska
3. California
4. Colorado
5. Hawaii
6. Kentucky
7. Illinois
8. Maine
9. Minnesota
10. Missouri
11. Montana
12. Michigan
13. New Jersey
14. New York
15. Oregon
16. Rhode Island
17. South Dakota
18. Texas
19. Utah
20. Vermont
21. Washington
22. Washington, D.C.
23. Non-ERISA governed policies in New Hampshire
Page 1 of 1
G-27041 12/5/18
Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
Authorization for Release of Information –
HIPAA Compliant
(Excluding Psychotherapy Notes)
To be signed, dated and returned by the insured/claimant.
Claimant Name: Claimant Date of Birth:
Claim Number: Employer Name and Policy Number:
I authorize any licensed physician, any other medical practitioner or provider, pharmacy benefit manager,
pharmacist, hospital, clinic, other medical or medically related facility, federal, state or local government agency,
insurance or reinsuring company, the Social Security Administration, consumer reporting agency or employer
having information available as to diagnosis, treatment and prognosis with respect to any physical or mental
condition and/or treatment of me, and any non-medical information about me (including any information, data
or records regarding my Social Security, FICA earnings history, Worker’s Compensation, State Disability,
pension, credit, earnings and employment history) to give any and all such information to American United Life
Insurance Company
®
(AUL) and AUL’s reinsurer(s) excluding psychotherapy notes and including, but not limited
to, any other mental or psychiatric records, medical, dental and hospital records (including psychiatric, alcohol,
and drug abuse, and, where permitted by law, HIV/AIDS information) which may have been acquired in the
course of examination or treatment. I understand that the information obtained by use of this authorization will
be used by AUL, AUL’s reinsurer(s) and the above-described representatives to evaluate and adjudicate my
current disability claim, and may be re-disclosed to (a) any medical, investigative, financial or vocational
specialist or entity, or (b) any other organization or person, employed by or representing AUL or AUL’s
reinsurer(s) to assist with the evaluation and adjudication of my current disability claim or another disability
claim insured by AUL and/or to report aggregate claims information to AUL. I understand that information used
or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be
protected by HIPAA’s privacy rules, or any other federal or state law.
This authorization is valid for two (2) years following the date of my signature. A photocopy of this authorization
is as valid as the original. I understand that my authorized representative or I have the right to request and
receive a copy of this authorization and the information to which it pertains.
I understand that I have the right to revoke this authorization in writing, at any time, by providing written
notification to Attn: Privacy Officer, OneAmerica Financial Partners, Inc., One American Square, P.O. Box 368,
Indianapolis, Indiana 46206. However, such revocation is not effective to the extent that AUL or AUL’s
reinsurer(s) have relied previously upon this authorization for the use or disclosure of my protected health
information. I understand that AUL cannot condition the payment of a claim on my signing this authorization.
However, I understand that my revocation of, or my failure to sign this authorization may impair AUL’s ability to
evaluate my current disability claim and as a result, lack of required information may be a basis for denying that
current disability claim for benefits.
**If you reside in California, Connecticut, Maine, or Massachusetts: This authorization excludes the release of information
and test results about Human Immunodeficiency Virus (HIV) and Autoimmune Deficiency Disorder (AIDS). A separate
authorization signed by the insured claimant or employee-claimant (for self-insured business) is required each time results
are released.
***If you reside in Vermont:
This authorization EXCLUDES the release of any information and test results about previously
administered HIV-related tests, including but not limited to tests for HIV antibodies, T-Cell counts, AIDS or ARC. The proposed
insured is NOT AUTHORIZING AUL to forward the results from any new test, requested by us, to any outside, non-affiliated
company or entity not under specific contract with us to perform underwriting services, and AUL shall comply, as applicable
with the provisions of Title 8, Section 4724 (20) of the Vermont Statutes.
Claimant Signature (or Authorized Representative): Date:
Description of Personal Representative’s Authority (if applicable):
(*If signed by authorized representative, attach verification of identity.)
Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
Direct Deposit
Authorization Agreement
New Direct Deposit Change to Current Direct Deposit Cancel Direct Deposit
PLEASE PRINT
Name: Social Security Number:
Please fill out either the Checking Account Information Section or the Savings Account/Credit Union Information
Section. American United Life Insurance Company
®
(AUL) will only deposit to one account.
CHECKING ACCOUNT INFORMATION
Obtain this information directly from the bottom of your check. Please include a copy of a voided check.
Name of Financial Institution:
Address of Financial Institution:
Transit/ABA Number: Account Number:
AUTHORIZATION
I authorize American United Life Insurance Company
®
(AUL) to electronically deposit all payments due me from
the policy identified above into the account identified above. I discharge and release AUL from further liability for
any payments so deposited to my account. I authorize AUL to pursue corrections, if necessary, to any amounts
credited to my account in error. AUL will notify me of the error and amount of overpayment.
Any such payments shall be returned to AUL by the Financial Institution if funds are available in my account or
shall be returned to AUL by me, my legal representative, my estate or my heirs if the funds in my account are not
sufficient to make the required correction.
I understand that AUL may terminate this electronic fund transfer at any time and for any reason and may make
payments by check instead. I also understand that I may revoke this authorization at any time by written request
which will be effective when received and acknowledged by AUL at its Home Office.
Signature: Date:
SAVINGS ACCOUNT / CREDIT UNION INFORMATION
Please obtain this information from your financial institution.
The information on your deposit slip is not applicable for this purpose.
Name of Financial Institution:
Address of Financial Institution:
Transit/ABA Number: Account Number:
G-28291 10/12/18
Page 1 of 1 G-24591 (Disability) (CA) 10/9/18
In the state of California, the following are hereby defined as unfair methods of competition and unfair and deceptive acts
or practices in the business of insurance:
California Insurance Code 790.03
(h) Knowingly committing or performing with such frequency as to indicate a general business practice any of the
following unfair claims settlement practices:
(1) Misrepresenting to claimants pertinent facts or insurance policy provisions relating to any coverages at issue.
(2) Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under
insurance policies.
(3) Failing to adopt and implement reasonable standards for the prompt investigation and processing of claims arising
under insurance policies.
(4) Failing to affirm or deny coverage of claims within a reasonable time after proof of loss requirements have been
completed and submitted by the insured.
(5) Not attempting in good faith to effectuate prompt, fair, and equitable settlements of claims in which liability has
become reasonably clear.
(6) Compelling insureds to institute litigation to recover amounts due under an insurance policy by offering
substantially less than the amounts ultimately recovered in actions brought by the insureds, when the insureds have
made claims for amounts reasonably similar to the amounts ultimately recovered.
(7) Attempting to settle a claim by an insured for less than the amount to which a reasonable person would have
believed he or she was entitled by reference to written or printed advertising material accompanying or made part of
an application.
(8) Attempting to settle claims on the basis of an application that was altered without notice to, or knowledge or
consent of, the insured, his or her representative, agent, or broker.
(9) Failing, after payment of a claim, to inform insureds or beneficiaries, upon request by them, of the coverage under
which payment has been made.
(10) Making known to insureds or claimants a practice of the insurer of appealing from arbitration awards in favor of
insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the
amount awarded in arbitration.
(11) Delaying the investigation or payment of claims by requiring an insured, claimant, or the physician of either, to
submit a preliminary claim report, and then requiring the subsequent submission of formal proof of loss forms, both
of which submissions contain substantially the same information.
(12) Failing to settle claims promptly, where liability has become apparent, under one portion of the insurance policy
coverage in order to influence settlements under other portions of the insurance policy coverage.
(13) Failing to provide promptly a reasonable explanation of the basis relied on in the insurance policy, in relation to the
facts or applicable law, for the denial of a claim or for the offer of a compromise settlement.
(14) Directly advising a claimant not to obtain the services of an attorney.
(15) Misleading a claimant as to the applicable statute of limitations.
(16) Delaying the payment or provision of hospital, medical, or surgical benefits for services provided with respect to
acquired immune deficiency syndrome or AIDS-related complex for more than 60 days after the insurer has received
a claim for those benefits, where the delay in claim payment is for the purpose of investigating whether the
condition preexisted the coverage. However, this 60-day period shall not include any time during which the insurer is
awaiting a response for relevant medical information from a health care provider.
(i) Canceling or refusing to renew a policy in violation of Section 676.10.
(j) Holding oneself out as representing, constituting or otherwise providing services on behalf of the California Health
Benefit Exchange established pursuant to Section 100500 of the Government Code without a valid agreement with
the California Health Benefit Exchange to engage in those activities.
In addition to Section 790.03 of the Insurance Code, Fair Claims Settlement Practices Regulations govern how insurance
claims must be processed in this state. These regulations are available at the Department of Insurance Internet Web site,
www.insurance.ca.gov or by calling the department's consumer information line at 1-800-927-HELP (4357). You may also
obtain a copy of this law and these regulations free of charge from this insurer.
Products and financial services provided by
American United Life Insurance Company®
a OneAmerica® company
P.O. Box 9060
Portland, ME 04104
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
Disability.claims@oneamerica.com
G-28203 12/19/18
American United Life Insurance Company®
a OneAmerica® company
Fax: 1-844-287-9499
Toll Free Phone: 1-855-517-6365
© 2018 American United Life Insurance Company
®
. All rights reserved. OneAmerica
®
and the
OneAmerica banner are all registered trademarks of OneAmerica Financial Partners, Inc.
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Disability Insurance Claim Packet Disability Claim Filing Instructions (Pensacola State College)

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Completed 25 August 2020

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