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Gap form 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by completing the 'Statement of Insured' section. Fill in your full name, date of birth, social security number, and account number. Ensure your mailing address and contact information are accurate.
- In the 'Patient Information' section, indicate for whom you are making the claim (yourself, spouse, child, etc.) and provide their details including date of birth and treatment location.
- Complete the 'Claim Details' section by specifying whether the claim is due to an illness, accident, or pregnancy. Provide dates and a detailed description of the injury or illness.
- Fill out the 'Authorization to Disclose Information' section to allow American Fidelity to process your claim. Ensure you sign and date this authorization.
- Attach all required documentation such as itemized bills and explanation of benefits (EOB) before submitting your completed form via mail or fax.
Start filling out your gap form today for a faster claims process!
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