AMERICAN HERITAGE LIFE INSURANCE COMPANY
CRITICAL ILLNESS COVERAGE CLAIM FORM
Remember it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important.
Please check to be sure all information is correct before signing. Please refer to the fraud notice specific to your state.
ABJ21587-4 Page 1 of 3 8/23
Submit Claims: Online at: www.allstatebenefits.com by Fax to: 1-866-424-8482 or by
Mail to: American Heritage Life Insurance Company 1776 American Heritage Life Drive, Jacksonville, FL 32224
For questions regarding the policy benefits, supporting documentation, or for claim assistance, instructions can be found on our website or
contact our Customer Care Center at 1-800-521-3535. Please refer to the Coverage Documents for benefits available as well as applicable
terms, conditions, exclusions, and limitations.
Direct Deposit: Please complete and submit our Direct Deposit (ACH) form located on our website.
Assignment of Benefits: To assign benefit to another individual or provider, please complete and submit our Assignment of Benefits form located
on our website.
Incomplete or blank responses may result in a delay in processing the claim request.
Section 1 – POLICY/CERTIFICATE HOLDER & CLAIMANT INFORMATION:
COVERAGE NUMBER(S):
POLICY/CERTIFICATE HOLDER INFORMATION:
First Name: _____________________________ MI:______ Last Name: ________________________________ Last 4 of SS #: XXX-XX-_____________
Birth Date:_____________ Age: ______ Gender: ______ Phone #: __________________________________ Email: __________________________
Mailing Address – We will update our system with this address and use this address to send future correspondence and checks.
Number & Street:___________________________________________________________________________________________________________
City: ___________________________________________________________________ State: _______________________ Zip: __________________
CLAIMANT INFORMATION: (If different than Policy/Certificate Holder)
First Name: __________________________________MI:_______ Last Name: _________________________________________________________
Date of Birth: ___________________ Age: ________ Gender: __________ Relation to Insured: □ Self □ Spouse □ Domestic Partner □ Child □ Other: _______________
Section 2 – CLAIM DETAILS. Tell us about the Claim.
1. Is this a □ New Claim or □ Ongoing Claim?
2. What are the Diagnoses/Condition(s)? (List all): _______________________________________________________________________
When did symptoms of this condition first occur? _______________________________________________________________________________
3. If Medicaid paid for services due to this condition, please provide the Medicaid Explanation of Benefits (EOB) and the Medicaid ID #: _____________
We may be required to assign benefits to Medicaid in accordance with applicable State and/or Federal Regulations.
Section 3 – Attending Physician’s Statement. To be completed by the Attending Physician.
1. ICD10 Code: _____________________________ Diagnosis: _______________________________________________________________________
2. When did symptoms first appear? ____________________________________ First Consultation: _______________________________________
3. Has the patient ever had the same or similar condition? □ Yes □ No If yes, when? ______________________________________________________
4. Is/was a surgical or medical procedure required? □ Yes □ No If yes, Date: _____________________ Procedure Code: ________________________
Procedure: ______________________________________________________________________________________________________________
5. Is/was hospitalization required? □ Yes □ No If yes, Admission Date: ___________________________ Discharge Date: ________________________
Hospital: ________________________________________________________ City: _______________________ State: _______________________
6. The patient is unable to perform their job duties: □ Yes □ No If yes, please provide the dates. From: _______________ Through: ________________
7. Referring Physician Name: _________________________________________________________ Phone #: _________________________________
8.
I am aware that it is a crime to fill out this form with facts I know are false or to leave out facts I know are relevant and important. I certify that the
answers given on this form are true, complete and correctly recorded.
Physician Signature: __________________________________________________________________ Date: ____________________________________
Print Name: _________________________________________________ Specialty: _________________________ Phone #: _______________________
Address: ____________________________________________________ City: _____________________________ State: ________ Zip Code: _________
Section 4 – Supporting Claim Documentation. Send us any documentation showing the condition, treatment, and/or services
received. This documentation must include the claimant’s name, provider name, and date of service.
Examples Include:
• Medical Documentation for the date of service that supports your claim such as: Hospital and/or Physician Office Records, Admission and Discharge
Summaries, Diagnostic Test Results (EKG, CT, MRI, Cardiac Catherization, Angiogram), Radiology Reports, Laboratory Results (Cardiac Enzymes,
Complete Blood Count), Wellness Testing, Pathology Reports, Operative or Procedure Reports, Physician Consultation Notes, Second Opinion, Therapy
Notes, Dialysis Initiation, and/or Home Health/Nursing Visit Notes.
• Additional Information (if applicable) such as: Attending Physician’s Statement, Physician Letter or Certification, Employer’s Statement, Incident
Report from Employer, Receipts, MapQuest for Non-Local Transportation, and/or Any Additional Information you would like reviewed.
For Waiver of premium, you must submit the Attending Physician’s Statement and Employer Employer’s Statement.
AMERICAN HERITAGE LIFE INSURANCE COMPANY
CRITICAL ILLNESS COVERAGE CLAIM FORM
Remember it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important.
Please check to be sure all information is correct before signing. Please refer to the fraud notice specific to your state.
ABJ21587-4 Page 2 of 3 8/23
CLAIMANT’S NAME: DATE OF BIRTH:
COVERAGE NUMBER(S): CLAIM NUMBER:
Note: Don’t forget to provide the supporting claim documentation.
Section 5 – CERTIFICATION: The Certificate/Policy Holder or Claimant who completed the claim form please read and sign below.
I acknowledge the receipt of the Department of Insurance Claim Fraud Statements provided with this claim packet. I have read the notices
and I am aware that it is a crime to fill out this form with facts I know are false or to leave out facts I know are relevant and important. I certify
that the answers given on this claim form are true, complete, and correctly recorded. Please also remember to sign and date the attached
authorization required to process your claim.
Signature:_____________________________________ Print Name: ______________________________ Date: _________
FRAUD WARNINGS BY STATE
NOTICE IN ALASKA, ARKANSAS, KENTUCKY, LOUISIANA, MAINE, NEW JERSEY, NEW MEXICO, AND VIRGINIA: 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 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 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 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 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 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.
NOTICE 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 thousand dollars ($5,000),
not to exceed ten thousand 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 imprisonment.
AMERICAN HERITAGE LIFE INSURANCE COMPANY
CRITICAL ILLNESS COVERAGE CLAIM FORM
Remember it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important.
Please check to be sure all information is correct before signing. Please refer to the fraud notice specific to your state.
ABJ21587-4 Page 3 of 3 8/23
CLAIMANT’S NAME: DATE OF BIRTH:
COVERAGE NUMBER(S): CLAIM NUMBER:
AUTHORIZATION TO RELEASE INFORMATION TO AMERICAN HERITAGE LIFE INSURANCE COMPANY
I hereby authorize any physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, health care provider,
Pharmacy Benefit Manager, insurance company, the Medical Information Bureau (MIB) or other organization, institution or person that has
any health related records or knowledge of me or minor dependents to disclose the entire medical record (excluding psychotherapy notes
and in MAINE and VERMONT HIV related test results) to American Heritage Life Insurance Company (AHL), its duly authorized representatives,
its subsidiaries or its reinsurers. This authorization extends to any minor dependent on whom insurance is requested or claim for benefits is
being made.
The information to be obtained shall include insurance claim history from any Prescription Drug Database, pharmacy benefit manager,
ambulance, insurance company, medical transport service, or the MIB. Also, I authorize any entity, person, or organization that has these
records about me, including but not limited to my employer, employer representative and compensation sources, insurance company,
financial institution or governmental entities, including departments of public safety and motor vehicle departments, to give any information
or record it has about me, my employment, employment history or income to AHL.
I understand that this information will be used to evaluate and administer my claim for benefits or to evaluate my eligibility for insurance. 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 certain federal regulations governing privacy and confidentiality, though it may still be protected
by state privacy laws or other applicable privacy laws. I also authorize AHL or its reinsurers to make a brief report of my health information
to MIB.
This authorization shall remain in force for 24 months following the date of my signature below or termination of my coverage, whichever
occurs first. A copy of this authorization is as valid as the original. I or my legal representative may request a copy of this authorization. I
understand that I may revoke this authorization at any time by sending a written notification to: Attn: Privacy Officer, American Heritage
Life Insurance Company, 1776 American Heritage Life Drive, Jacksonville, FL 32224.
I understand that a revocation of this authorization is not effective if AHL has relied on the protected health information or has a legal right
to contest a claim under an insurance policy or to contest the policy itself. The revocation will not apply to any information AHL requests or
discloses prior to AHL receiving my revocation request. If I choose not to sign this authorization or if I later revoke it, I understand that AHL
may not be able to process my application for coverage, or if coverage has been issued, AHL may not be able to administer my claim for
benefits and this may result in a denial of my claim for benefits or request for services.
Your provider may require you to complete an additional authorization form. If asked to complete this authorization, your prompt response will help
expedite the process.
Claims submitted on dependents 18 and older require an authorization signed by the dependent.
_________________________________ _____________________________
Claimant/Applicant’s Signature Date Signed (mm/dd/yyyy)
_________________________________ _________XXX-XX-_____________
Claimant/Applicant’s Printed Name Last Four Digits of Social Security Number
If signed by the legal representative, please describe the authority under which the representative is authorized to act and enclose any related
documentation granting authority.
__________________________________ ____________________________
Signature of Legal Representative Relationship
__________________________________ ____________________________
Print Name of Legal Representative Date Signed (mm/dd/yyyy)
