<> 0000001020 00000 n N)G#g,5CuOCl3ttm>moVq5\t:irQ`YOX`hI[-7k@LAI*:FcS$CfJQIJO'l@aSJln)/KXYQh;4`]9N;Qj "D=hF9Hc;3b+uU#87#u->Oo&ZR/kmg`A@Va9ssE1`$L205UY2\m1KJ?'g1*p?gL[/Z6a.dV! A0Y5rjtc-l=mpq_h=;$=@msV1)_!YAgb[=l4d[#_f!$4lHeElf,p`grp.1a3BKs:! <> $d"'aL\l#A%IE5_YS4O4h)$pN261/3.91=eY! Business owner? 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View Site <> 0000055045 00000 n qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib 5]mS)I&\m'[NsCj]sr@0El\`]Uq+.S367pgfd2I2(=P['dU+EV"7XqK'c7K%if?fQ]VP /Title (New Claim Form PDFs for WEB - S00224) 17 0 obj Explore the unlimited potential and flexibility that comes with the opportunity to become an Aflac insurance agent. lPl9tY-IJ%_lFQbBP+,UB6!AO?&Q*kaBs. endobj Aflac, excluding psychotherapy notes, and including, but not limited to, . ieO?mC^gEt3O?&]\X]CJV6:\OL%X;((>F1o\id;SSBij[G$R ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; endobj 3 0 obj 0JTM8HGN-uYUmTOelVf]F4AA)ZISHh>(!HVXe#12]a#X:Z;?uk$a0t'3>1o_N(G1e9TB>Kme4`U:>O6e Please choose an option. /2R!i5j&PBRjtAnemGT^T>r)/aH+##c99WL>k&k>=:> 29Q-bd"lOXj_`+YYr:EA4 Aflac Group | Columbia, SC oJ!qE004N-XBk;7k]qo&bs<9Pm9 ;Q@3tl%r2hiL>-riF2`as"IsW*9N`#MpX]d$ILH;\!q'76tN`)U0'B3Er(&1qB\DcHWYB!-Oqq@^._(U3Ebou]Ips^@!NDD'j)Wc0R;SN=Ru/abO]B3'i2!Ij,Q)U)kkGucg2heq!V;S <> 0000054815 00000 n 0000030858 00000 n "Jk(XbKsV#$D'i]&;mcIV!r /Encoding 4 0 R endobj Take advantage of the quick search and innovative cloud editor to create an accurate AFLAC Short Term Disability. endobj 17 0 obj Distribute immediately to the recipient. 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V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT endstream We pay claims fast. *Before filing a critical illness claim online, please ask your physician to complete and return the Physician's Statement Form*. 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Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the Pre-Existing Investigation Statement. I:V.I`2dr"RI-usXpWjkY@>M8)rABTHrdsdGSrnt>bM>*rdMgSo-0,QN0AdB$2JDlipKX1lo%-6ppko&)?kL6M8p"kK6P^Jj+s;af.%X>Efh47/[PqC. ;]2"WH3RN-IY-eA348fl;R6]T4%O*^emkHfI8Di4T'&!Ns\94;%b Short Term Disability Claim Form Instructions Aflac https://www.aflacgroupinsurance.com/docs/customer-service/claim-forms/group-disability-claims/disabilityclaimform.pdf Note: This form is for initial filing of a disability claim. 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R5BsS,N[X$9*1Su`V5!FLu53L/`5$Sl[7rqO,!^]g&GFP&S?ljI>6jN,bnDr8aF$lN\@CTOcGe"W!E$o endstream %PDF Font (F167) Simply select "File Online" below and follow the instructions. )S.%6`+GjIZj](Q#<=c@2$Z7dM/>T[*ou6=\86%`.6Tf9_%C^ECG2N>a#UsXf8l(9b*mV6r!V.s)b^~> 20 0 obj No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . m^PaP#$T,QfVQ'7kTb=#ja*O^[oT:q1qW?WH%a_Lp. 46a&g>*Zg/Di4fH;%L. ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; The Disability Claim Form (Aflac Insurance) form is 8 pages long and contains: Use our library of forms to quickly fill and sign your Aflac Insurance forms online. Individual Policies: 0000035380 00000 n InitialDisabilityChecklist Isdisabilityduetoasickness? 3 0 obj 23 0 obj /Type /Font <> You can provide this information in the designated space on the claim form. Apply your e-signature to the PDF page. If the accident resulted from the use of a motor vehicle(s), a copy of the police or accident report is required. 22 0 obj @lR;bed"/KM4=.N)6,FfJ&AfVrJm-US !7O$KXr'tSP>! Gl[`Vs#gklP69lm%%T22\kX&">D8=oK\TZW)P!IRM1g^=+9\uBMam13]#$n%@WS1?.N5'V*UaY%l0"YM endobj Aflac may include American Family Life Assurance Company of Columbus, American Family Life Assurance Company of New York, Continental American Insurance Company (marketed as Aflac Group), Tier One Insurance Company, and any other affiliated companies (collectively, Aflac), as applicable to the entity from whom you receive insurance services. 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'X-2uc/>cM8\5p/T44i`BgV5"LY/5Yg% 0000000000 65535 f endobj ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; GgU]JcO2rI@MJ!M*4mh6R`a.PLnCe-ET<>a;*-c;Tf1f )lM~> In CA, CAIC does business as Continental American Life Insurance Company (CAIC NAIC 71730) stream Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). ri$-h1/j[uMOPf3_2gQ%+)4Tt@BXW(2=KO%3;tVmZjc93ISZ#id:hb)o".^eIJY!Pf"3t`9hfK3>.oW& Aflac Group Policies: startxref endstream CNbe58Z\L9(JIf#nd8N&d;_Ve"&$B6Y;]TiZ`M2[D^dN\Eb5qm'qVJ='T'4DBH2tpG-/Q,o_g=%ZaF:Y DE.V"?h'jom'g4taZ=ggb[Rq9*%"D3_?>DBHcG"%EYhs\A)[02C%,[#:eC])1_\$c?cV\_3\d).P:QmEm*p#YH<04bhGCYr_BRigd-lMFY&qm3!U7+E'.29BdD[1$Xoi)[=&jM/3ntoZ9Yk9SnM:+ EMnIpA`\`j9p%8Jb%g?3bB@@W^$A.t>R)@AV[$Gr+1aic5NY;`=A9#XB->:2MDO^@t[9!^9`hM)b9[&5Hfki>iJ2*idRMc*I1K7B)P.Ht.`'k-.R`,bZ1``cJ c5lMh,QXUsVpDOgY[E488MHV?GK9DUk^qXiSo6?d"#T=f:;YTi0SU1_S\M2I.26bpPB\Xsl"fN>oQoH- Create your eSignature and click Ok. Press Done. 8;U4*8AZ=@b:l^dJ*L_0.&7i0E^jm_'-W 0000000686 00000 n %PDF Font (F38) 02rhl21qBSA"(T]mcU-(M+$l6hA!\lUur6,-iT#]. fKM7f%?5*K:i'+aV_K!?49DLRD(oBT]NI)%kf!BU%-f'rI-kJBX(Gn\B]/9qU,\iQ;,gU.Z@%@^>"[]W:T%89f)q@tlS'SN77! 0000000814 00000 n -_6'A_4IL[`92un&r8tH[>^"rhOWrgJZC\%6"6'k2kR6&.9EYCGWVonkFA2[(WQ.mndG'-IoKK^(VM6j):K)HmcRL+qg#Rf 3. ;dps@dXdX$3sN65dLrqK;34,XZ>#G6k1;= mQYc=\E9,ERP]c]=8bqqqY%CP/fB'k8=no-Ws101`o*'eZs]oap*qMF SUPPLEMENTAL CLAIM FORM (CONTINUING DISABILITY) (Please have completed for support of continued disability) Claim Number: PART A: POLICYHOLDER'S STATEMENT . endobj Except in New York, individual insurance and group dental and vision insurance is offered by American Family Life Assurance Company of Columbus. X3^f``c_A)\*/"78h!p%/*in2gI^?CblC`0:Dk,=U@Ip$RaFkC-A%5t[ObE/d?Sc8c!X5%k0qkA1$A(f 23 0 obj 0h_D=!TqJR_)(mgd\>#ol+75J9jtBIKFJ@V(i4JVZqc++3o&'Oo?S]N51A'u=i0pZ1o;C9[qgcc?S#Dh Aflacs Premium Life, Absence and Disability Services are available in all states, except Puerto Rico, Guam or the Virgin Islands, and are offered by Continental American Insurance Company (CAIC). Aflac Worldwide Headquarters | Columbus, GA endstream ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R j`\4ST^,:jc\SuD`L1I_)i;e_O'6;f$b?pm]7fCb6/VFNc7I[fZnuXU\MA`LdJnpE 0000000009 00000 n ^D"tO6srOZFP9$! 25 0 obj endobj R5BsS,N[X$9*1Su`V5!FLu53L/`5$Sl[7rqO,!^]g&GFP&S?ljI>6jN,bnDr8aF$lN\@CTOcGe"W!E$o endstream The user-friendly drag&drop user interface makes it easy to add or relocate areas. 0000001020 00000 n 24 0 obj 0000000326 00000 n 0JTM8HGN-uYUmTOelVf]F4AA)ZISHh>(!HVXe#12]a#X:Z;?uk$a0t'3>1o_N(G1e9TB>Kme4`U:>O6e 0000000212 00000 n rT)4FF1EPoVMN14>L,`\V:)bIb1npmugX^4,7NbhZ&&T,/8(>f=lM4?OnHSHRdi 4)&nf$tE5"g*2#E``6gl3H_U)RH)m.VU*-AYq=+#%i9Y7;)=6rhbKN=8id"8PGV#c1SW%K9D-r,8`1lZ [P'])96k0r/j-O-5R.B+?Ujtp8t.Wa^\9uALh!R/l:Z3W3Fi9-eo;Q)?QN/coX1HH='4^ -_6'A_4IL[`92un&r8tH[>^"rhOWrgJZC\%6"6'k2kR6&.9EYCGWVonkFA2[(WQ.mndG'-IoKK^(VM6j):K)HmcRL+qg#Rf <> 23 0 obj 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; 20 0 obj Aflac Worldwide Headquarters | Columbus, GA Have questions? 0000000563 00000 n * %%EOF, smuq7OH`g&f1$LYcjY7O,U0QT2BYHr_p^&[03aUoihTl0LFDN.ikW)D+ZecfR[[u4*@bg/rWb0P936uUo^J$CLiNn/3c].L=V.c). /BaseFont /Helvetica-BoldOblique fU$\OG4-O2)(5'UZNJ?f73M.5b:i7_h](4!r@! ;An6Y?l:#h=mlN1\Er endobj 0000000212 00000 n endobj To have your claims payment direct deposited, please download and fill out this Electronic Funds Transaction Authorization form. Products may not be available in all states and may vary depending on state law. 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