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Claim Form Assistance and Claims Checklists

Please use these checklists to make sure you have provided everything to keep your Cancer Care or Hospital Indemnity Plan Insurance claim on the FAST TRACK.

View Claims Check Lists

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
Wellness Claims
P.O. Box 9006
Phoenix, AZ 85068-9006

 

Mail any Claim Forms to the following address:
AGIA Affinity Services
Claims Department
P.O. Box 9060
Phoenix, AZ 85068

  1. Download and print the claim form (only required if NOT a Cancer Wellness Claim)
  2. Review the claim FAQs
  3. Follow the check list
  4. Mail your completed claim form

Submitting a claim is as easy as following these simple steps

  1. I have completed the claim form in full.
    • You can avoid delays in claim processing by completing the required information on the claim form.
  2. 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.
  3. 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.
  4. 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.
  5. (If applicable) I have included a copy of the pathology report that diagnosed my cancer.
  6. (If you've had coverage for less than one year) 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.
  7. (If you've had coverage for less than one year) 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.

Claim Forms Download

Download Claim Forms Below

Form Product Form Type Download
Cancer Insurance Claim Form - Securian Cancer Insurance Plan Claim Form Download
Hospital Indemnity Insurance Claim Form - Securian Hospital Indemnity Insurance Plan Claim Form Download