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Claim Form Description
Claim forms are available in PDF format to be downloaded, printed and mailed accordingly. If you don’t already have Acrobat Reader, it is a free application that can be downloaded at adobe.com/reader/
Mail any Cancer Wellness Claims to the following address:
AGIA Affinity Services
P.O. Box 9006
Phoenix, AZ 85068-9006
Mail any Claim Forms to the following address:
AGIA Affinity Services
P.O. Box 9060
Phoenix, AZ 85068
Submitting a claim is as easy as following these simple steps
- I have completed the claim form in full.
- You can avoid delays in claim processing by completing the required information on the claim form.
- I have completed the signature field on the second page of the claim form.
- Please sign and date in the space provided at the bottom of Part 1 of the claim form to verify all statements on the form are complete and true.
- I have included copies of the itemized bills needed to support my claim. If I received treatment at a Veterans Administration Hospital, I have provided the admission/ discharge paperwork and/or daily progress notes in place of an itemized bill.
- I have verified my itemized bills include the dates of service, description of services provided, the charged amount, the diagnosis for the treatment provided and the medical coding associated with my treatment.
- (If applicable) I have included a copy of the pathology report that diagnosed my cancer.
- (If claim date of service falls within the FIRST YEAR of coverage) I have provided the name and address of any physician who treated me in the year prior to my policy effective date in Part 2.a.
- (If claim date of service falls within the FIRST YEAR of coverage) I have included Part 3 - Attending Physician's Statement which has been completed by my physician.
Please note: If required information is omitted, this may result in a delay in the processing of your claim. Please allow 30 days for your claim to be processed. Should you have questions, please feel free to call a claims representative at 1-877-883-8800.
Click here to view or download the Claim Instructions PDF Forms.
Download Claim Forms Below
|Cancer Insurance Claim Form - Securian||Cancer Insurance Plan||Claim Form||Download|
|Hospital Indemnity Insurance Claim Form - Securian||Hospital Indemnity Insurance Plan||Claim Form||Download|
|Medical Records Release Form - Securian||Cancer and Hospital Indemnity Insurance Plan||Medical Records Release Form||Download|