Allstate Appeal Printable Form – Fill Out and Use This PDF

The Allstate Appeal Form is the official document policyholders use to contest a denied or disputed insurance claim decision. Allstate uses this form to give claimants a structured way to formally request a re-evaluation of their case, whether the claim involves health, accident, cancer, or workplace coverage. Filling out this form carefully and providing complete supporting documentation gives your appeal the best chance of approval. Click the button below to open the form and begin filling it out.

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Allstate Appeal Form PDF Details

When policyholders need to dispute a denied claim with American Heritage Life Insurance Company under the Allstate Workplace Division, the Allstate Appeal Form provides the official pathway for a formal review. This form covers a range of insurance coverages, including Wellness Screening, Intensive Care, Waiver of Premium, Heart/Stroke, and Cancer/Specified Disease benefits.

To complete the appeal form correctly, gather your policy number, the original claim denial letter, and any supporting medical or financial documents. The form must be signed and dated by the policyholder or their authorized representative. This form does not constitute an admission of liability or a waiver of any rights under the policy. Submit your completed form within the deadline specified in your denial notice, typically within 180 days.

For related Allstate insurance documents, the Allstate Wellness Claim Application is used to initiate wellness benefit claims, while the Allstate Critical Illness Form applies to critical illness coverage disputes.

Question	Answer
Form Name	Allstate Appeal Printable Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	Allstate, obstetrical, Claimant, designee

Form Preview Example

MAIL TO: American Heritage Life Insurance Company ∙ 1776 American Heritage Life Drive ∙ Jacksonville, Florida 32224-6688

CLAIM FORM

Has a claim been

filed before? Yes q No q

If you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our customer service department at 1-800-348-4489

8:15 A.M. to 4:30 P.M. Eastern Standard Time

Individual Insurance for:	q Wellness Screening	q Intensive Care	q Waiver of Premium
	q Heart/Stroke	q Cancer/Specified Disease

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.

This form is to be returned to our office at the end of each 30 days of disability or immediately if you have returned to work.

PLEASE PRINT CLEARLY AND COMPLETE FORM ENTIRELY IN ORDER TO AVOID A DELAY IN THE PROCESSING OF YOUR CLAIM.

A POLICYHOLDER

Policy Number:

Present Occupation:

Employer Name (Company/Address)

Name: First

Middle

Last

Social Security Number

Date of Birth

q Male q Female

Work Number: (

)

Average Monthly Earnings:

PATIENT

Name: First

Middle

Last

Date of Birth

Age

q Male q Female

This person is your

(example:

self, wife, son, etc.) Is he/she a full-time student? q Yes q No

Please attach itemized bill(s), including date of service(s), diagnosis code(s), procedure code(s) and charge(s)

B6. What sickness or injury are you claiming?

7. List all doctors who have treated you for this condition: Name/Address

Phone Number:

8. Have you received treatment, medication or advice from a doctor in the past for this or a similar condition?

If yes, give date:

Doctor’s Name

Phone Number

(

)

Address

C 10.

Dates unable to work:

q a.m. q p.m. to

q a.m. q p.m.

11.

Dates confined to your house

q a.m. q p.m. to

q a.m. q p.m.

12. Have you returned to your main (or principal) duties?

Date returned part-time

Date returned full-time

If filing for premium waiver, physician and employer must complete reverse side of form.

Important: To avoid delay, please sign authorization below.

Note: Due to Internal Revenue Service requirements concerning social security number verification and backup withholding requirements, this form is required to be completed prior to claim payment. Remember, it is a crime to fill out this form with facts you know are false or to

leave out facts you know are relevant and important. Please refer to the notices below for notice specific to your state. Check to be sure that all information is correct before signing.

1. Section 125: Were the premiums for your disability income policy paid with pre-tax dollars under a Section 125 Plan? q Yes q No (if in

doubt, please ask your employer.) Taxpayor Identification Number Certification

2.Federal law requires us to send to the Internal Revenue Service a percentage of any income you may be entitled to unless you certify under penalties of perjury that you have shown your correct Social Security Number and you have not been notified that you are subject to any Internal Revenue Service backup withholding order.

Under penalties of perjury, I certify that:

A.The Social Security Number shown in line (1) is my correct taxpayor identification number (or I am waiting for a number to be issued to me), and

B.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) The IRS has notified me that I am no longer subject to backup withholding, and

C.I am a U.S. person (including a U.S. resident alien).

I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medically related facility, insurance company or other organization, institution or person that has any records or knowledge of me (or my dependents) to give such information to American Heritage Life Insurance Company or its designee. 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 American Heritage Life in writing of my desire to do so. A photographic copy of this authorization shall be as valid as the original, regardless of date signed. I understand that 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. The Internal Revenue Service does not require your consent to any provisions of this document other than the certification required to avoid backup withholding.

Sign here _______________________________________________ Date:_________________________ q Check here if address is new

Claimant

Street Address:______________________________________City:____________________State: Zip: ____________Telephone No. ( ) ___________

Allstate Workplace Division is the marketing name for American Heritage Life Insurance Company (home office: Jacksonville, Florida – ahlcorp.com). All products are underwritten by American Heritage Life Insurance Company, a wholly-owned subsidiary of The Allstate Corporation (home office:

Northbrook, Illinois – allstate.com).

W-4213 REV (12/02)

Page 1 of 3

ATTENDING PHYSICIAN’S STATEMENT

	Individual Insurance for:		q Wellness Screening	q Intensive Care			q Waiver of Premium
			q Heart/Stroke	q Cancer/Specified Disease

	D Patient’s Name							Age

1.		Diagnosis: (Describe complications if any) Is condition due to pregnancy?			q Yes	q No

		If “yes”, what was approximate date of commencement of pregnancy?			Date – MO/DAY/YR
2.		When did symptoms first appear or accident happen?			Date – MO/DAY/YR
3.		When did patient first consult you for this condition?			Date – MO/DAY/YR
4.		Has patient ever had same or similar condition? (If “yes”, state when and describe)				q Yes q No

5.Describe any other diseases or infirmity affecting present condition.

6.Nature of surgical or obstetrical procedure, if any (describe fully).

Charge for this procedure and where performed?

Date – MO/DAY/YR

If in hospital,

q in patient

q outpatient

Please attach itemized bill(s), date(s) of service, procedure code(s) and charge(s).

Is patient still under your care for this condition?

q Yes

q No

If discharged give date

Date – MO/DAY/YR.

If patient is/was hospitalized, give name and address of hospital.

Hospital

City

State

Date admitted – MO/DAY/YR

Date discharged – MO/DAY/YR

10. How long was or will patient be continuously totally disabled (unable to work)? From Date – MO/DAY/YR

through

11.If still disabled, when do you expect patient to resume full duties?

12.Name and address of referring physician if any

Name			Address
City			State			Zip

PHYSICIAN VERIFICATION

Signed

, MD

Date – MO/DAY/YR

Phone (

)

Street Address

City/Town

State/Province

Zip Code

Remember, it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important. Please refer to page 3 for notice specific to your state. Check to be sure that all information is correct before signing.

EEMPLOYER’S STATEMENT


1.	I hereby certify that	did not perform any part of his/her work from,
	to,
2.	When recovered, will he/she resume work?		If not why?

Remarks

Name of Employer		Date	Address
By	Official Position		Telephone number (	)

Northbrook, Illinois – allstate.com).

W-4213 REV (12/02)

Page 2 of 3

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 DELAWARE, IDAHO, INDIANA, MINNESOTA, NEW HAMPSHIRE, 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 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 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 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 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 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 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 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.

NOTICE IN DISTRICT OF COLUMBIA: WARNING: 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 TENNESSEE: 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.

Northbrook, Illinois – allstate.com).

W-4213 REV (12/02)

Page 3 of 3

How to Edit Allstate Appeal Printable Form Online for Free

How to Complete the Allstate Appeal Form

Follow these steps to fill out and submit your Allstate Appeal Form correctly:

Gather your documents. Before filling out the form, collect your insurance policy number, the original claim denial letter, and any supporting evidence such as medical records, physician statements, or receipts.
Fill in policyholder details. Enter your full name, mailing address, date of birth, and policy number in the fields at the top of the form.
Describe your appeal. In the explanation section, clearly state why you disagree with the claim decision. Include the date of the original decision, specific coverage types involved, and a factual account of the dispute.
Attach supporting documentation. Include all relevant documents with your form: physician statements, diagnosis codes, itemized bills, and any prior authorizations related to your claim.
Sign and date the form. Your signature certifies the accuracy of the information provided. If you are filing on behalf of another person, attach the required written authorization.
Submit the completed form. Send the form and all attachments to the mailing address or fax number listed in your denial letter. Keep a copy of everything for your records.

Common Questions About the Allstate Appeal Form

What is the deadline for filing an Allstate appeal?

The deadline is typically stated in your claim denial letter. Most Allstate policies require the appeal to be submitted within 180 days of receiving the denial notice. Check your specific policy for the exact timeframe that applies to your coverage.

What types of claims can I appeal using this form?

The Allstate Appeal Form covers claims related to Wellness Screening, Intensive Care, Waiver of Premium, Heart/Stroke, and Cancer/Specified Disease insurance coverages distributed through the Allstate Workplace Division. If your claim type is not listed, contact Allstate directly to confirm which form applies.

Can I file an appeal on behalf of a family member?

Yes. If you are an authorized representative or designee, you may complete and sign the appeal form on behalf of the policyholder. Include documentation confirming your authorization with the submission.

Where do I send the completed Allstate Appeal Form?

The submission address or fax number is listed in your original claim denial letter. If you cannot locate this information, contact Allstate customer service for the correct mailing address for your specific coverage type.

For additional insurance appeal resources, review the Aetna Appeal Form if your claim involves a secondary insurer, or use the general Appeal Form template for other insurance providers. The Appeal Request Form is another option for formal appeal submissions.

Allstate Appeal Printable Form – Fill Out and Use This PDF

Allstate Appeal Form PDF Details

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