aflac disability form

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Bk\1f/VUX4ST4NT40lN34+-*[pI_iW#ggd2*`hgWE^=-R:s=)2'tu01Vr]^_S>-&.RS7)o+'X@(Y83/( pVm0rYNePYi@2CrKlf(0`O9(:4lsA`"DB*V_2?OtI(:IK1s$SV]W0j\bo[2VhWP2Ff.O9.oYUrAMp$ endobj Aflac Worldwide Headquarters | Columbus, GA C)U\u?j:;&T7I/iGm[n\T;_)`gEYqdm*YLN@N-_eg4^hU\]H7Co2_+ugag&:Fd?U>McjOT-(PdfS7Ma7 Z'qla+"Ni'F7cdihoHcj(u=..e%DbtGJWZF/nB*]I!`;q;hE9aN=iqM2-6r0A.0!kYlX,(D Do Not Sell or Share My Personal Information. 02rhl21qBSA"(T]mcU-(M+$l6hA!\lUur6,-iT#]. e(d`r+1(IK_Z9J8FZEKhh]p"mOP2o\*_i:B,oR:q;pr&)1JfnGrF_2WN1&RdVP7b@X=`\9QI&,k/0N4e %%EOF, ^#$J_1B!E\jQnDo*AZEPW#Q5HmqO\,o&d+LqKX0];I^YQ!dK5/)RRb8kQ;c1SD&I_aWfY7X h.*.:`/`($FjUjeMh+%3^KDbf? "DFX!Fen1$B29'W4#sWKq 0000037564 00000 n 0;p5g%:Gd\>Io0dB\q^f8G>h/i$&$eAg8lGgN!bHFN/%]=BXD&^?mb,/u7t)rbDTL)pZ8Q"RdB*(8=i? The Attending Physicians statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. endobj @lR;bed"/KM4=.N)6,FfJ&AfVrJm-US endstream <>stream !$"P3qfbXDLeQ[oZ1B!OZ7r(l@ fKM7f%?5*K:i'+aV_K!?49DLRD(oBT]NI)%kf!BU%-f'rI-kJBX(Gn\B]/9qU,\iQ;,gU.Z@%@^>"[]W:T%89f)q@tlS'SN77! 22 0 obj endobj Business owner? 0000000009 00000 n 15 0 obj /5&*Q)*,WjJn8+=I9EJW%)B]4Nh Direct to Consumer individual coverage underwritten by Tier One Insurance Company. 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY h.*.:`/`($FjUjeMh+%3^KDbf? $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K /Title (New Claim Form PDFs for WEB - S00224) 0000001020 00000 n Gb"/,D/UE'&cO9g'Le5&-SP5UG1U(.gN&eaNpA_5Jen>pld`Ep3L8bprUnu0/pTC:L6'E&Oj6GD1q3j9aEcrf34m?(SYF9tiIC:9reE'%4hLa2A@q$X^Gul'8"j\_Z*Pnco=On_l;2u]$YT1JT1XNYZ$TWMcEU?(Ui>2@/K'qS2q=(qBpq<3n9RGEE0_8LAA>/$)9CPnE%+9ApaZ,q%!Z@U^=:+[a/uKS+%k1MN.5&^;J?&K;ie$ki31!T(>`p4Q/r^7M/gh:/g6\RiOpi02X8?9HDKNojiqH\fTkO*reW@;YqPcC9h-__*61?X3pEIK=-:Mg`CsmZsnd)H'+=n"uJWaI(c]kOWO`2UbM90f_0;rj"kWn=h4\6e+LchC?K(aad&A+d=lL_&TFbfmX0*Jd>>Lmhg']bd[,I"5X<0AA:^98ST=TL-W*EXj/?&T;_5X\sh.,]!.A7hkAL;K9,acI9;+t&)dF!#U9p7>)1ab(?k%('sei:-fSqGn8$875]6O?=iNSbFZPYbpfpi\fF=d!TWfO9_A*9i`E)g2nb9[]r6;B*+jn@3B*E8a.o&10@UPpd.#Fim\Qt3S_6srHr(cgA(HP-!=E1fm'jAS%[WEUY45$jA:1*!"_h4>,'ed0`:"U?a%>q5Sk8O%L5/-VbJOt%f[Wo5&+7ZWm)`Q\MtViQg@s#N?!#?+?55mL6n4[sHFW/%Oik>,,Q49TgBiiV=`lNki3%%cN37#n.#\jo&]u\b'SQXMkff2Z+:=E__ba,4,fbGl/%NfT1%mTOhR@Hp$eX`Q]NApHg(O!T!T,JX>YrfSc*XWe,tK-f@fjb!:P5SWnUq[raVb_pulJ5eg_;UrRuPp?]KMK'N[_*8]%m5lE/MnE-j/@_"piL`o$2b!5KmcMpl\QuKQe6cFt3d"QU/8VhMg61_(pFa[DgRo[/kl'*[iUgQtmpPAY@e=1ORRB\T@Y&ni:rb-NZ2i]/;Pbn)Ua2u6L(qd)ks=?'-P66*a*#!,#`\V:ShknH6?EG@*f;6o,.]tj+)KVD%`C'e%R(78-Y!,'>d7S46qeQgD:X.>@?&V#IDL,ZUABl.bFR0(2V)lAN)QF^Y:VNJGr,<0^9+mg(4kS?=%M/O;&RHQR.kY_:0U+3UiT0l;08h3,bP>Tsj5U^SoN_Cou8K3moS,"K9`Z`;s5*o9lCWSLVQ2bfj&klQ409JYQ.(1Jl'B%@9$i@pmb)GV`ANI^.?,OrNXq7rn!RPR*pKnG0";)$hnRY3Na_+4eo`l*Rf[7V7$BT;Hq&6m\*m^I>!#d$>&;?T+`ccsgY1q0]B[PIc;."8N4h08/D5'K7A*nV2KdGFWT"^SSIs:V1$^@,MDm-V,+oO6JtnX^/m[cEq`!?rH3`YI0cmWR"8g$/C/.+P\:)5[8jO$t!d\KSmXNOEr%:bg*AT5!?I0h75@nQ5rO)*(jd=kNcAd7$W=#YU)gJ_)^\D]!duA4Y#&>q6Wh!_O+IiRBMqDTm9H"-I'2m"XKZPJq?9=O95Od2JW(,0eXenP6H2L3)sWB\,I1e$uGg%):=Zg9it2S=Qa%FBIWcqqI$?UN5n=LFCbrrPG=QD4*5Zh.r,t?fL@e+`WG8)KnFiMJqn>N2aW.H/Rc*'uj0Ln97(H.aF2tMHd1M/o9KXDQHF9/UT9&QIUTI5Z82l?!=7]TLuX?-^'Ff"b^Z]e9-nn8_nN1:>j@91NTeBp%-W*,UW'0;Zs+%MsoCUq__]ahrQ_?>IQtA07A:.r4XV,T,mLf]ShS4914P3kYD^)KhQ:[^>JVT?pg*\ktXteM3K3s*[#Xa(ZV&cjs1Top:ClIhp]a[qR%]G^Xg)-Y?Sn.p8p=9Qk>UhQ6`jRmo3_uY(Q9Ma%Q'r/PbX`Wka@$F@Iut5SCH[:e%)nl;j]Ta@fK%i=_M>uWQ'2@?H;h8ar*=UOR,2o`fQu@+QH)K-piLh/a-J"&>^@kT996'GcZ1(8.2(tkUlu^Gupc7)bEOcBTBm"XLiL\0!$>_J7/I2=;%P5VulZgVP91SIms>4HT;9\Y5a_hi]denkL19?h/]=3eF=hVhIbn/++t$3W6].KQgAH_#eOk#HA7ZDGm>D'=T0pGhAA&F#'9L9GAB6!^R6WI!_BNY0Yg-kl%&U,+ic[XbJ)8hqNnKJ>-a`4LS>d^+JE>lKa#%)Xu?13'+ca'WIEAOd?Y6$MtOP1K``[PW*!2n[$qQI3]OSB^[OfBB!ijns;OJk#L^/:e0XaG+cKJ>&dt_VCu9jE^Kf?`Rt$Q^WKJI7c?2#D%4&i"5BA,\DhaPFbfHO&Y(E]r/[[6VNDn9*o+7*TbdQVpTNJP.4pbT=%Rf:]dN6bM+&god8d+B1,J;UNK-WBi)#Zuk8Hid\*WHp^BUXt$&_e"h%rWCICP'/ABL#24>X/e"*0oIS%1e)_V1%n.[J:%9?t/!G'Ti],DoOCBF]CA)YH+:,b.s(t1a)=hr]j8(f@EM;/b7l6(ai4c#LGHkL$o071#7)J9GY4gTVr#:'T=*QD_kt=`&9Cq_=Xd,Nke/#%!)34-M[ro998>9bnD/N>iqjE_\p0*BsnqTkiK_`6'DA?s.n7P3k)JPSQZG4D'G%h?8?%%HP@tr"8;u*u@73kB6`*9^G&jQ#K>MGcB5cQlXdqS^NjY3Id)%u/Sd5s^gcP&tT[f&Gn""Y^):oK,/\:NdSg@JJ?bRD7(3aKua`XgV;VRMfo2Ys9rhoL85bT%##/ff'Xl`^[P$5JLicJnrEsLEZ^]WLhGAXBOG3gc&1TR(CI]Ca2"In8:G)T)"VR(2!cO_.44"pNn$R>Zo"aD2\A*;KDHn/%A^Djt+U*T3?U=(9%UbRZ!L8E)t!"Q6+]#6^gmNh;-"l=lJRiRpdU:\_\\Ia=)Q6)V18ar)8JCkGq@N@3n*jg^&t_18^[Td/g^(=b)9.EXV/PU!nl,@SVbf[=QO0E4RVKB4.dh_cT;'?(l@*@Y`rN=H*e1/+7u]a,s#ITK7eqBO"[J0KCfX!mWFh6f0qf-pE]N5DCsG8I5<8WSngn$-cT-W^YT38)gM?-rCP^'-r0`Y&tsg_ncDO:%EN+k7;rH1j!k*2k!VrJrWEbHQQ?.%ajJ#`H!O7gE4I9_h>$Ai7O@>O;%0-$BNcRrmtbUb:u+Xb^g7:Y^bZp$i[K#[M;p_))3%#VZCou%b9;UBi>.srIrE3#D.'KLV$nt%#Wq6k)$U(b$o%5]TAbfR;9cgi#WVmE,aj8rTSdC.OGL1fCjOiC?d#HNPE<>gnjZnRrET1FM5h/Euj(#f9d")3O2'YqId"-U:*".(^\q101NEm#WAO5? 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Submit your claim online 24/7 Manage your account, submit and track claims, setup direct deposit and more. endstream m-*&@,H9g(2[5#o!G;R4U9IEG=[4#Wq9g71 0000055045 00000 n <>stream Please provide a date and complete description of your accident. rT)4FF1EPoVMN14>L,`\V:)bIb1npmugX^4,7NbhZ&&T,/8(>f=lM4?OnHSHRdi eiE#q%9eO%886=-()4_+S4PR>Y.OpD>thDms)r(iY76&nF\4eSBh"@D8Ckg?OT/fVbq-a!hKg2P8WFKC*e*%O1YLY&R&=h#U$ <> J"!Z$KNf!aNfZg$c3f9Eif:$>6XgnJ_+WZ+>UN`D_090Sk6pr-./XCf.RcJoIeeA$283Wm0>IEa1k;_GenLoF#=W7kAbUSPPYkck"W#[d8g/CEK/Qj&fT8,quS8O4;583SMLnm&$C16R.4cCjYs)h@>WY-)F #uY.o`Vd[Bd.YT[///3UJY[r*;n,NhjZnQjdJ7=`r$)Ri)3:i(@X2#3?N.HcWa:.*$kP? ?M?uK\`[L'MVpgq.\;DFhc?I3,E@L<5O.H'In/5-%oHIk6Y].-91Vsi8;^S7T-@bW-s/Y'OlKTsB7_NY endstream View Site Aflac Initial Disability Claim Form Capital Insurance Agency Aflac Initial Disability Claim Form Fill out Aflac Continuing Disability Form 2019 in several minutes by following the guidelines below: Select the template you need from our library of legal forms. Aflac Continuing Short Term Disability Claim Form Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf Please note: The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee's Form W-2. American Family Life Assurance Company of New York | Albany, NY . 0000000932 00000 n 0JTM8HGN-uYUmTOelVf]F4AA)ZISHh>(!HVXe#12]a#X:Z;?uk$a0t'3>1o_N(G1e9TB>Kme4`U:>O6e For step-by-step tutorials on filing an online claim, please see our claims checklists. 0000000446 00000 n endobj (@(usgg(FDHdtq_aekmXE(BC6eG1C/8GXuO:=']]5O,*cYeJ6rL_T-&cqtYOG-PZ=N]XFkICN-m,r>>:_tp?- 3 0 obj POije23\6G%qCTitHV>Xor, endstream stream 0000040092 00000 n 0000037564 00000 n Aflac Short-Term Disability Insurance pays cash benefits for covered disabilities (subject to exclusions and limitations). <> endstream 8*C9[J(Cl:;Gi9qfiditHQ#'L]jC2sPgd`'`W#[3J"LQg0%?W3t_5VRgmCJ5=M#ORRY\sAH6Rq;5+ChV$?jn,^o9SGo>Ha If this is an Employer Sponsored Term Life Product with your policy number beginning with AFL, please use the forms below. If the cause of death is an injury or accident, include a copy of any related police report and/or newspaper articles. ?NAW 0000000446 00000 n If the accident resulted from the use of a motor vehicle(s), a copy of the police or accident report is required. 6,k1;gaBDk.XY%J:F9As.#C&J>pqd^X_`2(g"7EVNm@*ELI1%cI SUPPLEMENTAL CLAIM FORM (CONTINUING DISABILITY) (Please have completed for support of continued disability) Claim Number: PART A: POLICYHOLDER'S STATEMENT . %PDF Font (F7) 8,Y5:-bZ-;Z%c':c]*),@W=_c. This form may be used on all product claims except Group Term Life, Group Whole Life and AD&D claims. trailer<> A0Y5rjtc-l=mpq_h=;$=@msV1)_!YAgb[=l4d[#_f!$4lHeElf,p`grp.1a3BKs:! /2R!i5j&PBRjtAnemGT^T>r)/aH+##c99WL>k&k>=:> 18 0 obj Submit or View Your Claim For critical illness claims, we need information from you and your attending physician. /Encoding 12 0 R endobj <> << 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. endstream jPHFW8nlme]HU. Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r ;]2"WH3RN-IY-eA348fl;R6]T4%O*^emkHfI8Di4T'&!Ns\94;%b 5 0 obj nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. health plan (including CAIC or Aflac, with respect to other CAIC or Aflac coverages) or health care clearinghouse that has any records or knowledge about me. 14 0 obj 0000054815 00000 n '1L#-Ne#BOUYn.SL> endobj 6 0 obj 15THsJWlVj?FW\)knqP*Lk! )_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~> 0000049332 00000 n Your dentist should complete the Billing Dentist section, Boxes 4266 (excluding Box 53). endstream mhQCujn[DM`k5Vu9TL8/lY,n@)69`YnLctGSmP1C9g-Y\7nk0=`m#b/(aquK(k!OU2OhA)L%au^_^KfM 23 0 obj 0000000446 00000 n <> *?ZgaJ72F%->d4aYIUb3reE0'[sM)3JY+[(7="R\fM6;Q 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. 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employee onboarding form template