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Get American Fidelity Assurance Company Bn-723 2014

Disabled. 1. 2. 3. 4. 5. Complete Statement of Insured and Statement of Spouse in full. Have the treating physician complete the Attending Physician s Statement and return to you. Have your Employer complete the Employer s Report of Claim. Submit the completed: A. Statement of Insured and Statement of Spouse B. Employer s Report of Claim C. Attending Physician s Statement to the address below or submit via our toll-free fax 1-800-818-3453 Please complete if you desire b.

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