Accident Claim Form

WALMART GROUP ACCIDENT CLAIM FORM AND INSTRUCTIONS

If you have any questions regarding benefits available, or how to file your claim, or if you

would like to appeal any determination, please contact the Walmart Claim Department at

1-800-514-9525, 8:00 A.M. to 8:00 P.M. Eastern Standard Time or at

www.AllstateBenefits.com/mybenefits

The furnishing of this form, or its acceptance by the Company as proof, must not be construed as an admission of any

liability on the part of the Company, nor a waiver of any of the conditions of the insurance contract.

• To avoid delays in processing please fill out the sections which apply to your specific claim.

• Include your certificate number. To obtain your certificate number, you may call 1-800-514-9525 or visit our website

at www.AllstateBenefits.co

m/mybenefits.

• You may fax your claim to us at 1-877-423-8804 or scan and electronically submit your claim through:

www.AllstateBenefits.co

m/mybenefits.

• You may also mail your claim to: American Heritage Life Insurance Company

P.O. Box 41488

Jacksonville, Florida 32203-1488

• Please be assured that your claim will receive our prompt attention. If you would like to receive your claim proceeds

even faster, Allstate Benefits can automatically deposit them into your bank account or on your Money Network Card

by completing and returning our ACH form (ABJ16661WMT). This form can be found on our website at

www.AllstateBenefits.com/walmart

• Additional claim forms are available on our website at www.AllstateBenefits.com/walmart

INSURED AND PATIENT INFORMATION

1. Insured’s Name: First: Middle: Last:

E-mail:

Certificate Number:

Social Security Number:

Date of Birth: / /  Male  Female

MO/DAY/YR

2. Daytime Phone Number: ( ) Evening/Cell Phone Number: ( )

3. Occupation:

PATIENT’S INFORMATION

4. Name: First:

Middle: Last:

5. Date of Birth: / /

Age:  Male  Female

MO/DAY/YR

ACCIDENT DETAILS

PLEASE DESCRIBE YOUR INJURY:

Date of injury: / / Time of injury:  a.m.  p.m.

MO/DAY/YR

Where did it happen? Tell us exactly how your accident/injury happened:

Did your injuries occur while you were working for pay or profit?  Yes  No  On the job  Off the job

Have you ever had a similar injury?

If so, please tell us when: / /

MO/DAY/YR

ABJ10368W-5

Page 1 of 4

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INSTRUCTIONS FOR FILING YOUR ACCIDENT CLAIM

Following are the benefits available under your Wal-Mart Group Accident Policy. Please check the benefit(s) you believe

may be due based upon your injury. You will need to attach itemized bills, including date(s) of service, diagnosis,

procedure code(s) if surgery was performed, and the charges incurred. We may also need:

 A copy of the accident report if the accident was investigated by the police or sheriff.

 A copy of the blood alcohol report or drug screening if the patient was tested for alcohol or drugs.

 A certified copy of the death certificate if the patient is deceased.

*Additional information may be required as shown below.

The following are benefits available under your coverage:

Immediate Care Treatment Benefit



Accident Follow-up Treatment



Hospital Confinement



Initial Accident Hospitalization



Dislocation



*Radiology report or physician note confirming dislocation

Burns



Skin Grafts



Eye Injury



Lacerations



Fractures



*Radiology report or physician note confirming fracture

Emergency Dental Work



Coma



*Medical records may be requested

Brain Concussions



*Medical records may be requested

Surgical Procedures



*Operative report may be requested

Major Diagnostic Exams



Physical Therapy



Rehabilitation Benefit



Appliance Benefit



Prosthesis Benefit



Blood/Plasma and/or Platelets Benefit



Ambulance Benefit



Transportation Benefit



Family Lodging Benefit



Intensive Care Unit



SIGN THIS PART ONLY IF YOU WISH TO ASSIGN BENEFITS TO A PROVIDER OR A FACILITY

I request that American Heritage Life Insurance Company send benefits to someone other than me. Please send benefits available to the name and

address shown below:

Name

City State Zip

Relationship

Address

Provider’s Tax Identification Number

Signature of Insured Date

Important: To avoid delay, please sign authorization below.

I authorize any physician, medical practitioner, hospital, clinic or other medical facility, insurance company, the Medical Information Bureau or other

organization, institution or person, that has records or knowledge of me or my health to give to American Heritage Life Insurance Company (AHL), its

subsidiaries or its reinsurers any information relating to my claim. A copy of this authorization is as valid as the original. This authorization applies to any

dependent on whom a claim is filed. This authorization is valid for a period of 24 months from the date signed. I understand that I may revoke this

authorization at any time by notifying AHL in writing of my desire to do so. I or my representative may receive a copy of this authorization by supplying

policy number(s) and Insured’s name in a written request to the company. (In MAINE – I understand that revocation of this authorization may be a basis

for denying insurance benefits. Failure to sign an authorization statement may impair the ability of a regulated insurance agency to evaluate claims and

may be a basis for denying a claim for benefits.)

Sign here _______________________________________________ Date:_______________________

 Check here if address is new

Claimant

Mailing Address:_________________________________City:____________________State:_______ Zip: __________Telephone No:. ( )________

ABJ10368W-5 Page 2 of 4

ILLINOIS INTEREST STATEMENT: For contracts issued in and residents of Illinois, unless payment is made within

fifteen (15) days from the date of receipt by the company of due proof of loss, interest shall accrue on the proceeds

payable because of the death of the insured, from date of death, at the rate of 9% on the total amount payable or the face

amount if payments are to made in installments until the total payment or the first installment is paid.

FRAUD WARNINGS BY STATE

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 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 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 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 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.

ABJ10368W-5 Page 3 of 4

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 thousands dollars ($5,000), not to exceed ten thousands 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 confinement in prison.

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