Mail To: Bankers Fidelity Life Insurance Company P. O. Box 105652, Atlanta, Georgia 30348·5652 CLAIM FORM Toll Free Claim Number: 1-866-458-7499, 8:00 A.M. to 5:30 P.M. (EST) www.bflic.com Has a Claim been filed before for this loss? .......................................................................................................................... 0 Yes 0 No Policyholder Name (First, Middle & Last) Street Address Date of Birth Policy Number o Check here ifnew address I( (City, State & Zip Code) I( Home Phone Number ) Work )hone Number & Ext. Social Security Number Male Female 0 I Age Patient (Rrst, Middle & Last) 0 Dale 01 Birth Patient's Social Security Number o Self o Spouse o Son o Daughter If patient is your child, is he/she full-time student? 0 Yes 0 This Claim is for: 0 Accident o Disability o Medical-Surgical o Medical Indemnity o Medicare Supplement o Hospital Indemnity o Cancer (If claim is being filed for cancer, enclose pathology report) o Other Patient is your: No What sickness or injury are you claiming? List all doctors who have treated you for this condition: Name/Address Phone Number Have you received treatment, medication or advice from a doctor in the past for this or a similar condition? .................. 0 Yes 0 No If "Yes,· give date, name and address of physician: If you were hospitalized: Date admitted Date Discharged Name of Hospital Address ACCIDENTAL INJURY: (Attach copy of police report if auto aCCident.) (A) Date of injury (B) Where did it happen? o AM. (C) TIme of accident 0 P.M. (D) TeU us exactly how your accident 11<1p1-'t::01 (E) 0 6n the job o Off job (If on the job attach Workers' Comp report of injury) (F) Did your injuries occur while you were working for payor profit? ~ 0 Yes 0 No (G) Monthly Income Date first sol.lght treatment Dates unable to work Dates confined to your home A.M. OP. M.to OAM. OP.M. o P. M. to OAM. OP.M. OA.M. Have you returned to your main (or prinCipal) duties? •.•.••••••.•.•.•••••••.•.•••••••..••••••••..•••••••••..•.•••••••••••• 0 Yes 0 No Date returned part-time Date returned full-time Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing . any false, incomplete or misleading information is guilty of a felony. Authorization To Release Information I hereby authorize any physiCians, practitioners, hospitals, clinics, pharmacists, insurance companies, employers, credit reporting agencies, government agencies and other persons or institutions to furnish Bankers Fidelity Life Insurance Company or its authorized representative copies of any and aU information, data or records you have regarding any illness or injury, physical or mental condition, medical history, consultation, prescriptions, treatment, or employment pertaining to me. I understand that I have a right to request a copy of this authorization. A photocopy of this authorization shall be considered effective and valid as the original. Dated: Signed:X Insured or Beneficiary . If you are claiming disability benefits the reverse side of this form must be completed by both your employer and attending physician. CF-01 (2-02) EMPLOYER'S STATEMENT Employee's Name Date of Hire Date Employee Was Last Actively At Work (Complete on evety claim) Total Disability: Between What Dates Did Employee Give Up all Duties? Why Did Employee Cease Work? From To Month Oav Year Month Partial Disability: Between What Dates Did Employee Perform Only Part Of Duties? From Month Year Dav Date Returned To Work (Month, Day & Year) Day O'nlury OVacalion DQuit Year DOismissed DTemporatY Layoff D Leave of Absense To Year Month Dav Workers' Compo Claim Filed For This Disability? .•... 'OYes ONo Has Employment Terminated? DYes ONo If Yes, Date Terminated "Attach 1st Report of Injury. Employer Authorized Signature Address Print Name Phone Title Date ) ( ATTENDING PHYSICIAN'S STATEMENT IAddress I City I State I Zip Code Patient's Name Age I 1. Nature and origin of injury Diagnosis (Describe complications, if any) Confirmed by X-Ray? OYes ONo 2. When did symptoms first appear or accident happen? 3. When did patient first consult you for this condition? 4. How did conditions originate? ICD-9: Date (Month, Day & Date (Month, Day & 5. Has patient ever had same or similar condition? .......................................................................................................... 0 Yes ONo (If "Yes,' state when and describe) 6. Describe any other disease or infirmity affecting present condition. 7. Nature of Surgical or Obstetrical procedure, if any. Dates OClosed Reduction Open Reduction Metal Fixation Description Procedure Code Dates 8. Give dates of treatment, and nature of treatment other than surgical. Office OHome Hospital Nature of Tit:CllIllt:llI;) 9.ls patient still under your care for this condition? OYes 0 No If discharged, give date 10.lf patient hospitalized, give: Dates of Confinement: Name and address of hospital 11. How long was or will patient be continuously totally disabled (unable to work)? From To 12.ls total disability expected to be permanent? OYes 0 No Expected date to return to work 13. How long was or will patient be partially disabled? From To 14. Please list name and address of referring physician or any other physician who treated patient for this sickness or injury. Name Address Name Address o o o Physician's Name (Print) Degree Physician's Address (Street, Cilyffown, State Of Province &Zip Code) Telephone Number CF-01 o Tax Identification Number (3-08)