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0000054519 00000 n 0000049332 00000 n 0 27 <> Aflac promised to be here when you need us most - and a big part of that promise is making the claims process easy. endobj Your employer is responsible for providing the information in Part B, and your attending physician is responsible for providing the information in Part C. In addition, please read and then sign the Authorization for Disclosure of Health Information (HIPAA form) included in Part A, as well as the separate Authorization for Disclosure of Health Information (HIPAA form). 19 0 obj 0000000446 00000 n 19 0 obj No Yes Isdisabilityduetoaninjury? endobj o5BD$*Z2jom$PZ&;ZZZSrkbZVqI! >> Please fully complete the claim form for the Wellness Benefit. (0h]6sfh&ctrb/lSmDh5-O.iae,IL6uU^p;6R$coc.i2=RBLFrO3lTLkd^8
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Once completed you can sign your fillable form or send for signing. <> Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F
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File a Disability Claim File a Hospital Claim File a Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claim File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company Claim Aflac Group Insurance Additional Forms Authorization to Obtain Information Form Direct Deposit of Claims Payment Form 0000043584 00000 n HQ$ujRc"9@)AC83@/u';(.AU@8h[,dM5@MBi91i8@]+f5P8hFJ11.%Ec:Brs4lZA';_labWMQK7-EQHe
endobj <> Execute Aflac Initial Disability Claim Forms To Print within a few minutes following the guidelines below: Choose the template you need in the collection of legal forms. (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!AicdVn^"gp(^-oKqo#i"gBOsIn1fK.\PJgLt&^imq7BSJ..gu`g3TNp]lZQ:Q+PSQZ=7bSOhN`;B#7;s#7r)aO+XB?-BFdCkA(+.VnQp*5O$?iSK/`O.QJ'S)/aPDmhO:I1AIuZ^Ves%d@6'UQ5gRhf3BF`kXpaej\IRil\Y_Tp',^\5b3DiW.2X/9G,ZBZNQ1%0jnNTP=-/t4]pG5O*!$Hj%$(Vi!33gU7QS]rt"S4I%1~> "Jk(XbKsV#$D'i]&;mcIV!r
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For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York. 3 0 obj 3. Self-funded plans and absence services are administered by CAIC in all states but NY. 18 0 obj "\1ceiPob[!+@J3(3TJ)YX)OUj[W9&;I:dYZ=kc)4eebY'g`kA>>[&O][obn/UEdfgRXrat28;.HM:HQa#NGoYVo#="o%! <> Aflac Short-Term Disability Insurance pays cash benefits for covered disabilities (subject to exclusions and limitations). GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. If you are filing for disability, please complete the Initial Disability Claim Form (S00224). You can now make your claim online by accessing your online account. For groups sitused in California, group coverage is underwritten by Continental American Life Insurance Company. 0000043584 00000 n 55184 endobj <> Consider filing online for faster claims payment! )_uYFAPMnh@@qLR(!tj0,JgDV:^2aU1j,Q1G5%+A&.^pn]C"PJA:oAllMYj0psPAVZ_E,8iGS^\I&;A'/E"CXIR`WpK_.^,?uB7C2c/q!Ft;r%bq\)j#XX/c~> stream Universal Life Insurance underwritten by Trustmark Insurance Company. ;Y'TZ`#NiWQ
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m^PaP#$T,QfVQ'7kTb=#ja*O^[oT:q1qW?WH%a_Lp. Please provide all information requested on the Insured's Statement portion of the claim form. If you are filing for a health screening on your Hospital Indemnity, Accident, or Critical Illness plan for Coronavirus (COVID-19) testing, select Biometric Screening as your exam. 0000000932 00000 n Aflac Short Term Disability To sign an flag initial disability form right from your iPhone or iPad, just follow these brief guidelines: Install the signNow application on your iOS device. <> 0000030858 00000 n <> 0000001422 00000 n endobj 0000049332 00000 n MLS# 1864249. FXd-mhfj\dS((^`0K6!.q%j)EYH;^Rd.Aa`hf%gahFK:H:&//7pMV3D2qV#r4Oea\q/upjBMGec[O,Y:5n_u^Q$*P(4j$+WU5q!\lQS0:!H;gK
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