Customers of the Listing of Companies publication From 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Statement of Insured' section. Enter your full name, account number, mailing address, employer, date of birth, email address, and telephone number.
3. Indicate for whom you are making the request by checking the appropriate box (Self, Spouse, Child, Other) and provide the patient's details including name and social security number.
4. Select the benefit for which you are claiming by checking the relevant options listed. Ensure that you refer to your policy for available coverage.
5. Complete the 'Authorization to Disclose Information' section. This allows American Fidelity Assurance Company to obtain necessary information regarding your claim.
6. Once all sections are completed, review your entries for accuracy before submitting via mail or fax as instructed.

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