Our customer service representatives are here to assist you Monday through Friday 9 a.m. until 7 p.m. Eastern time. /2R!i5j&PBRjtAnemGT^T>r)/aH+##c99WL>k&k>=:> *?ZgaJ72F%->d4aYIUb3reE0'[sM)3JY+[(7="R\fM6;Q Coverage underwritten by American Family Life Assurance Company of Columbus. :JP2npQHaeod^X7'sK!^CIY561O?2S)MJ3_5]Y=4,Cn7b%K5Me(p[?9MOo\lj=] Life claim forms for the state of Illinois must be obtained by contacting Aflac Worldwide Headquarters at 800.992.3522 to have the appropriate forms sent to you. If your certificate number issued to you is in a numerical value, Example: 1234567891, please only use the two forms below. 21 0 obj [W_J1(2pZ1HC$V;V*/7\3N-"m8ACA6(\G4_j7tLZo4PDu:9kltQ:qtrOFJei`3u25)_cfnQ2M,M>*2Sb 0000000563 00000 n 21 0 obj IsNhEk,PeVb^BZe[*I4rabcN&lDZ'ULHK+-T$;u]WD3GH('p*58J'[(3mgr(:*0TR2iG4M503dao>uU! Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r "k&*mXEOTDY; The Attending Physicians statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. `JaOS[A]]e$%M7QS4Qo!meJ)_CS:m7V7-aS4FZ1PGi:"6tO9;>TbWc_tC3LGp( -_6'A_4IL[`92un&r8tH[>^"rhOWrgJZC\%6"6'k2kR6&.9EYCGWVonkFA2[(WQ.mndG'-IoKK^(VM6j):K)HmcRL+qg#Rf >> )toiFe(5W*JmS'IeRpMhRM\E^RfC)>n7:/sPgsY5E^.`.P>\/9SK;2 CNbe58Z\L9(JIf#nd8N&d;_Ve"&$B6Y;]TiZ`M2[D^dN\Eb5qm'qVJ='T'4DBH2tpG-/Q,o_g=%ZaF:Y V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT @lR;bed"/KM4=.N)6,FfJ&AfVrJm-US 3. If this is an Employer Sponsored Term Life Product with your policy number beginning with AFL, please use the forms below. <> (V.ea8oM1meVG5&2$R&VHdRmbM`,/jQ'iTTlk_NLi7Pu8>hqB>F6,at#]$=1\UL'_o 0000001422 00000 n -8KU)@AZCLegJ8ge%BBp0g(_Y&;BmiFJfS%>@Gu7. 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PolicyholderInformation:This*denotesarequiredfield. fU$\OG4-O2)(5'UZNJ?f73M.5b:i7_h](4!r@! TiH!-bXfof5[n@&[kS/JgZ:HFlTDHBWer?faRZL Aflac Group | Columbia, SC lPl9tY-IJ%_lFQbBP+,UB6!AO?&Q*kaBs. endobj HQ$ujRc"9@)AC83@/u';(.AU@8h[,dM5@MBi91i8@]+f5P8hFJ11.%Ec:Brs4lZA';_labWMQK7-EQHe nhH(@HB3(k..$A&2I&hNumCF[&]PjI*`R_D2M6]X>#-E#f;915&(PF6%>9Knd"E.:PO 19 0 obj +-,&SN`[I-M6qW3;r1s0&Z$T=BbN][5p[;h9H7KL(+uC\p]Q8pinC7ha3-F4WH*,lCOr\XdV:L)GI3LX 25 0 obj endobj Direct to Consumer Business is underwritten by Tier One Insurance Company, doing business as Tier One Life Insurance Company in California (Tier One NAIC 92908). endobj View Site 0000000814 00000 n "D=hF9Hc;3b+uU#87#u->Oo&ZR/kmg`A@Va9ssE1`$L205UY2\m1KJ?'g1*p?gL[/Z6a.dV! View Site Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf Yku1YRdk^9;TD\;*kl4jYjTa8Xl"SC:fUS)e;!AcrDK#l16`LFaGhEJ;`,G>'H*8^Jr\^>/E?FZ]1S?b 0000043584 00000 n !o5ERV47$k+S(!Xa"PN!I9]Y4"VHDRe8O[\PP>C\n_[q%@(=l5'/%#n49 0000055045 00000 n "\1ceiPob[!+@J3(3TJ)YX)OUj[W9&;I:dYZ=kc)4eebY'g`kA>>[&O][obn/UEdfgRXrat28;.HM:HQa#NGoYVo#="o%! 0000000326 00000 n P\D=1Pt+K^bCr/L=R_+?]7:K8ND*^rZJ>\)+SO$sqSJ1VT+A'Q-ShdfdhK\Q%N%LoP*mTJ1U1["BmoP?0"U1GH. 0000001422 00000 n *Before filing a critical illness claim online, please ask your physician to complete and return the Physician's Statement Form*. s(a2"ShqZon2tUR"gff@QgRi&=8T@kgq-(JZ&gl35W-8HGs$[[cMe ([eH#15RQ9*WFJq0`khPI=$2a3*8h8?\)&pGHS--no]E3Z-HiTg Aflac Group | Columbia, SC QQZnEET3`^=L@5Inq5fkUd?/3Y2`;02=IqDob^'R&m,FG.6*VIW,-bt2>#UYOZJj>;fU1^9uM()U8*1b endstream stream 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 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H? -_6'A_4IL[`92un&r8tH[>^"rhOWrgJZC\%6"6'k2kR6&.9EYCGWVonkFA2[(WQ.mndG'-IoKK^(VM6j):K)HmcRL+qg#Rf @oGDmsuR- !^`!O2!InjU(e3U7YceUPSbUm,".#RY6kVt+9Vg5'L]Mt+EU">H4*U`'^6l6 ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d Gb"/+>Ak37'`KV3/5eDEgG?/lI4LWa'$ur?W[d*V,h\7l#d?mNJ)Aq(`l\$9r]8mD9i4oAk0uTg\R00ZVV#pc.2Mpm+,=coq-^X\/^2+Ro:*!h7Bm]Cq>98`j38rMql+RHlciXDD:O-.R9_TU-%$KWJ&%EeDSQOMS%tsI0d4a7r9#Ol4'D%E4EK1ujsb..`iHm]`e$)k^"Q^#KkEYKkH,uOP(80*7Z5_G4.i#]hLJ+";I[!$12hJ91\8^[Td+XQ[mPo$8j=s\t4"S,Bl$P(;O%p!s!Ku[I>D!+-:qp&44s&b-79$g5X8KRm;i)J?CM@uJaJZ3^-Eoca:2/860Oi73ej_sH/OffcPpc'hdKu0-^ag$H2rn97h7g81oHMqEm$5MWrPmpU?7DD#UMab$5%_[b_8>?O8;6s">eu$N?n%Q3o!,Df>u?kJq2$m(FDMD"##D'#q#CTD?)CYs'$I(M@4F-U::15Q%CU1Ro3Znq41#6.+o_=5ii9S"&"'.+G;+5G!,8*WI.NQditfNp9BF#01UA\LPkPqV*j[??CiX;jR$FZSrI"OH.>ON%;Ij+oGrA6_YW^6Z:!B#$R,Fga=;d&7Zk($aUr))R"L3#^biuj386G.RNZLhK?kf]F0C&fq"inaEpKV4E2>X7d8DIY6;Od8q0GVqWGT#j0+5q;T=*+akW/tBoYQZ.c%]"Z=@H@m>d&O9S+u."e1@+;2U6W%)#".951Q^Z6=7m[06H>UTb9BB]]glBFmRjNR5\N62KH_K>KYfo+E%Frhsu6TYdn\:>Kr^8ZIITr1#;ZZF>&LhZH?p%;L"7B&5Gaa=8<>M&:elHR^d4hNj[S!V$=Me)\^I&hPmkGd0/QWmOLQegbEX,A28`%VVVgJ`0\b(?LY4aeE3T!+!4FA>+S26ZT+Ed!jr*!@8f9GrZ2q4^e]="@ec#*$7\..9,ltUZ9q^eON_e:e%(!Kr*o./j1.p&=]K^rjJBVaGFUOgr45.]M%0dIX02r,f!NFbT5k42%b2k\MC#%\(4sUMj[6p`^1<>g'nP4]>\lG^]-Q)'CTnjM'o[`6*$PjK+BrkMHD4-^)R-/Z(SRB6#G_eY*]&-Q-,K,\)d@;keV2q;l.W;?kHXKR"tW"h:3>=R$Wt$KTEFmQ7r^^[N'B^a!Sb[u7NG^1HW6hGC_j$97psFCSS((]FUF>k4CG%[Y^c^5&QoktoiXau4dM^'1J.I6gA.h-?X<8t,sDhU@I7WWUL(U)&bG*FWGeFY`f'W_-n)(^0F7WjosHEeYC,WDPPDqbj?f1Y)IC"7k_H(rZu^!\6VZ"Fac7jM>lmos.nt"CGREi"b7BHP35;PQtiF"Y1Pb/A3fP"%2/kf7(!A:",b6i%gA>LWNPaR"+2'4e"QPBY'qVb"KM^pc_eAmpUIh#*-Ln\RsSU2i:)Ldl[:U?4_b#H/MgO*cPThRX*eUeTc%[*`L%TM=2\3\BN3Z*tTlg]Y>_&0]U+n.bDg0DdPK*X)BePkCk\ms&+Dkos;Ka3=K/fXjT.?,t!-IbTfJUp=jf:8T_2&s'+(/.h=j/O9fh(^YS'Co7!4#IZV(+Pfu#A/KIARp[>2\:3q(PedG.mRZ.4B:e1fDag*F#o4Ersmuq7OH`g&f1$LYcjY7O,U0QT2BYHr_p^&[03aUoihTl0LFDN.ikW)D+ZecfR[[u4*@bg/rWb0P936uUo^J$CLiNn/3c].L=V.c). Except in New York, individual insurance and group dental and vision insurance is offered by American Family Life Assurance Company of Columbus. Submit your claim online 24/7 Manage your account, submit and track claims, setup direct deposit and more. stream 0000054624 00000 n Yku1YRdk^9;TD\;*kl4jYjTa8Xl"SC:fUS)e;!AcrDK#l16`LFaGhEJ;`,G>'H*8^Jr\^>/E?FZ]1S?b [P'])96k0r/j-O-5R.B+?Ujtp8t.Wa^\9uALh!R/l:Z3W3Fi9-eo;Q)?QN/coX1HH='4^ )lM~> And the best part? *WS>mdrX4a@K:\2X]Y(aJJnXSIKj37?5&F)>s:B7il/.16"r!2ThTJ5PA3j'f^*7d4SNu%N>--MA'!$L 'oHV-TGH;:1osTnm1H 8*C9[J(Cl:;Gi9qfiditHQ#'L]jC2sPgd`'`W#[3J"LQg0%?W3t_5VRgmCJ5=M#ORRY\sAH6Rq;5+ChV$?jn,^o9SGo>Ha endobj 21 0 obj e(d`r+1(IK_Z9J8FZEKhh]p"mOP2o\*_i:B,oR:q;pr&)1JfnGrF_2WN1&RdVP7b@X=`\9QI&,k/0N4e X3^f``c_A)\*/"78h!p%/*in2gI^?CblC`0:Dk,=U@Ip$RaFkC-A%5t[ObE/d?Sc8c!X5%k0qkA1$A(f :JP2npQHaeod^X7'sK!^CIY561O?2S)MJ3_5]Y=4,Cn7b%K5Me(p[?9MOo\lj=] /Length 310 @mT@XKG9gfV9sjgJ:!#'gnJe-hrK2RiqoM==]mG(t!Vd6O=URG3 0000043507 00000 n 24 0 obj 0000000009 00000 n . o5BD$*Z2jom$PZ&;ZZZSrkbZVqI! DCl*mJUg=pq^:YnVX2rH-?MoX;V+!pDt12?)+Ag/%cNZV^V$#m+E*A#TQr? Beneficiary's Statement for Death Claim Form. I)%]TcA`mWhX>Fb(1P"hjhfpCIF@eR>[8Uk8jb3JJCK>D0o*mhlN*%U(90mDYL0F##rb&>4GjbSZj8#' endobj [lXipns%dYmtWgT45TNAg1!L7&LsF1AVS8,9_:a+p=0JYXs63uqK)DZMF:+=COnscG]5l!0l_(jD#HTn3T/Nq3TXul_X>mcZ"L&H2kUp].^k.4,_Aof>Ug=,=b3fQf+d*!6h*m;*04i'C0/[p+\Sgs.&*IjrlVLg~> ieO?mC^gEt3O?&]\X]CJV6:\OL%X;((>F1o\id;SSBij[G$R J"(P!B[I`dqF4n.TukTr5!ON]W=HA3mG[gs/&`.9cLAu2;f?1f)+,ck.qKD:83!]6. The University is committed to a policy of equal opportunity for all persons and does not discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, or veteran status in employment, educational programs and activities, and admissions. 0000040092 00000 n %PDF Font (F27) rT)4FF1EPoVMN14>L,`\V:)bIb1npmugX^4,7NbhZ&&T,/8(>f=lM4?OnHSHRdi stream 0000000009 00000 n The Attending Physicians statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. Aflac Group Policies: DE.V"?h'jom'g4taZ=ggb[Rq9*%"D3_?>DBHcG"%EYhs\A)[02C%,[#:eC])1_\$c?cV\_3\d).P:QmEm*p#YH<04bhGCYr_BRigd-lMFY&qm3!U7+E'.29BdD[1$Xoi)[=&jM/3ntoZ9Yk9SnM:+ /2R!i5j&PBRjtAnemGT^T>r)/aH+##c99WL>k&k>=:> :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! ?&2QmV4C.$NuL;0P(Z7tk6M XjUu*Xp,0:=B'1\[JFP0hMrY:2"oGp)9[K*JFW%Q,%O]LqIHbC]M^O"otS`QEp1e73#AH7.C_?r+Be5\ Once completed you can sign your fillable form or send for signing. mQYc=\E9,ERP]c]=8bqqqY%CP/fB'k8=no-Ws101`o*'eZs]oap*qMF ([eH#15RQ9*WFJq0`khPI=$2a3*8h8?\)&pGHS--no]E3Z-HiTg P\D=1Pt+K^bCr/L=R_+?]7:K8ND*^rZJ>\)+SO$sqSJ1VT+A'Q-ShdfdhK\Q%N%LoP*mTJ1U1["BmoP?0"U1GH. _0kQ98&!$i3)qj(aoD$GE4ichZTh10fLUX?o`T)Tp(DKE$D,A)o)nXcqGjE4Kf$SW?d(38p]9$)m%!a_ American Family Life Assurance Company of ?f48_G,BN0p=/>&*)"gUTVU[Y>F[!H0S$cH]UJRYpFnh6'Ae"7a6i,,,Lbtk3(JMM]r0XUgZr>L@0I'i 16 0 obj U;s(7Es'Hq&:@a]^0oUGCJa3R7thK`//"XdS%5f,bl:[\>V0EGJX9:R[P$&(L2fO4E"!r*bnZA.0JbrSKY5@2H. 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GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. /5&*Q)*,WjJn8+=I9EJW%)B]4Nh A(lCW]h%VdMt:8Y)JTJc(@p\,K2F73Vt)lr]_VGs^b4MoT7ZmT:ZlP&6C?-PWabHK;JrCnJnrcc nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/, hE&QFc^dIdG#.H18:@0U,pbR1i0OHr%ZD%"dUD1"DuY4>c0PkmD1%2p#>4jE,*9"aVX9!`oVXR;d-Y3"Hq'?Sn=O;D/S!.>c4I`[@q^TH. 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CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. )qT)jZA=U\YiCp>=mtH$[\__]9X3fUD/SEtnbat` 2. MLS# 1864249. (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!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~> endobj A&!R^maAJpBZW3)>! 0000055045 00000 n For Sale - 1420 W 1700 N, Provo, UT - $599,000. 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Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F Take advantage of the quick search and innovative cloud editor to create an accurate AFLAC Short Term Disability. Please provide a date and complete description of your accident. pVm0rYNePYi@2CrKlf(0`O9(:4lsA`"DB*V_2?OtI(:IK1s$SV]W0j\bo[2VhWP2Ff.O9.oYUrAMp$ endobj 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$Xoi)[=&jM/3ntoZ9Yk9SnM:+ *-ogCe2UsEgf\'ds_/jiZfh5I(c[]]fP=H[DUhhQ4'/;X2hk?KsbO!`rDQ2eS&bFI1P0&@J-^!k9`KO(igH\q^TX%?G:9) Please submit the pathology report used in the diagnosis of a malignant cancer, the claimant's birth certificate, and any itemized medical bills with the diagnosis and procedure codes, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). !ncB:\VKdEm`qT:*N=[JNN2d(=N=eQCP0@YV._+qhu3A\"7SbVdlGbB#r@F8W,NFT7X_+Li_!4M/4=!o 0000037564 00000 n endobj Execute Aflac Initial Disability Claim Forms To Print within a few minutes following the guidelines below: Choose the template you need in the collection of legal forms. 0000049255 00000 n endstream 93^8SlqmQZ!1De"\u*GfeLd;np?nPWYSd67)d]ch=uD%XiFi:dZhC'MhDK8OlZ2*YHmB.O$)Wh[*"R,, The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee's Form W-2. 29Q-bd"lOXj_`+YYr:EA4 ]/:~> <> X3$l$UUC.Q8bG%FB^qod-T(^7g7U9j!? _^7`jFRJiik^>[sr;K_R=oP`RhjIDn7[PIg5,_,"obk"U42[,7b`:kTqB'Do)liYcA9l:=H+qjE). stream 2#Uk88j6F;!LPJCYg?_VnT>DO7>((M$tI28>B]"L9/3#3R1],d$6!$JJRKV2m(tG_Q]-T()Va>`2T]>l;eK>s(U,g-lu^? 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). >> /ToUnicode 13 0 R ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; 55184 ]Ic'l[Ucs$aC(lNOL3_Hu70AR(nl%uh/8Mpt4L2j*61I9N5(i,IR;G@j;#["p&LU,X>BR_AYKK6.R/dNK"(^)?d.HOT8Opb0Y-K\%)C64ibd!\^el)-+>j:\a[jWR6/W"V7$&<2ChQ4GQ3m]%-]eU36,7(7&j^8g0t0._o5#)MF+=O0%0JZsOU541%";UhbOU541$qhQCX^U/X4>K3,D$=_4r%W\&S\MZi0BE\KZCLf\GR)(H"TPAbB>9a5R_bAOr9WH[a\MZ.8'b&$<8)CZC!4q/$KA=egJk37Y-1E[86[%\Q8F@Ib#lC'QaPAJ_!-i/?KdVG"X#_=\516`^^\5J,M/.DIa\*YoK("Ilc7:\Z!R!s#oBE\L=Mo^G"0[nG`5V"#mcLGq-fm(][p0CmKXlc98[>OE;Z/7+o2eE!LDjPa!a3Xc:0DZRWnntJY5N;J?0eM/NN[?FDc1*_BD4,fH?NW^RLYY)!s0cFkh7TIbZO^6D,e>Dc*8`HqDdK^f5,@XY;DpFtX]=7B\)[5Tnfu-3$sRuHF:Yh5'IV`6%-m4Y.bOGfjZ)(qBXT;C[`r?0DD5;2)a8.>B\E]#K4+#M?QZ,2jt>l2-a^eJUVSD!$n^V+2KS`Z(&b7f>D\c[,cbDnI4RtYNNY'\j^e:/MTc%[.&Mi>Z89csFkO_me;R=pA8XQ.='6KHrksNkk*r9FX=S4Pgr\U>)LU5Z,0PIFd?h1K=.dmASs68D`.HQBQ8=FLf"fMskfFj8:[Dn597>tbl?nmbEA5SDre>S,3Deg@^FLUSDBA)p%)5RIVgXbP`on^-X@s(>%\g1:1g-Ajr[lATDl@UCM[dLm)1Q1+HU#b])Erj(I@+9m#p4k5]ncg6)T6;E!O;b->F7sSX?aRu-P@hC&7M%b&g/\9Yd'&gar3\#MN%b[$3Y2%,([$$!Sb:YTWCG]j2+aG"2aZ-"`S]Al;)59HFIu;io(nY/H9B@6iFQi3XdcW9Z-V6BgCIF"eCT9P\"M`BQi15C1'7&VWI5c1I.s(>fq'HRp]Cb$Rqk,?C+Y'I/&mA*)/fjc@on>V1EDFR>i9ni(>e6,gV6[.`lEk#T#^0>n4cs+"I$9AbNd6MMHmgP(.+9DS]%Au*>#2LX^T9h_]SOMI20Cj1M&?NqGF(B;h9Cqf?G2iM0gOD]RR;E$7UJHl(Vc3,?YgX1JCUp$h)/n="5=st8J,~> [W_J1(2pZ1HC$V;V*/7\3N-"m8ACA6(\G4_j7tLZo4PDu:9kltQ:qtrOFJei`3u25)_cfnQ2M,M>*2Sb <> %+7qEQTFU"'i_\(/=gq+JNS@%Y-$pZB>:Y4*(rCZfQj@Kgqq^GWEccM#up\R$:Ie]Cf@mqFQ&(pWqBMr $s?SXVcf%'C4RJ(8`-)k.!R/tmOC4@"`:#!%j`_M[6BFOHB#O$NY5c1rOEh=kBspt>`NP'>;a[EcIDPt Open the aflac initial disability claim form physician's statement and follow the instructions Easily sign the aflac disability claim form with your finger Send filled & signed initial disability claim form aflac or save Rate the aflac disability forms 4.7 Satisfied 292 votes be ready to get more Create this form in 5 minutes or less Get Form If your injury occurred on the job, a first report of injury filed with your employer must be attached to the completed claim form. <> "DFX!Fen1$B29'W4#sWKq 46a&g>*Zg/Di4fH;%L. Please fully complete the claim form for the Wellness Benefit. endobj endobj <>stream m-*&@,H9g(2[5#o!G;R4U9IEG=[4#Wq9g71 (D;A)'1,bTSu(P!sL=W[AP?iW[gGM $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K )F9)MP$gjIIV>!H All forms are printable and downloadable. 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We built our online claims process to save you time and to help give you peace of mind. 0000054442 00000 n 24 0 obj endstream <> 26 0 obj Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claims. <> <> 0000043507 00000 n 0000054815 00000 n I:V.I`2dr"RI-usXpWjkY@>M8)rABTHrdsdGSrnt>bM>*rdMgSo-0,QN0AdB$2JDlipKX1lo%-6ppko&)?kL6M8p"kK6P^Jj+s;af.%X>Efh47/[PqC. endstream 0000030858 00000 n For disability claims, we will need information from you, from your employer, and from your attending physician. [P'])96k0r/j-O-5R.B+?Ujtp8t.Wa^\9uALh!R/l:Z3W3Fi9-eo;Q)?QN/coX1HH='4^ ]_h\LUlKWpDX[03gS"tG,UJ0*mL9UkEk%7OIX,#u6?P_/\,44Z>m2`cW$i)b*qRV/6raU^h/W^<6?6JC;$U>eK_"kZBZcu]&\dTh"\!Q%B8?1?Rk8,^p^Wn[RC5_%c^'XQF+or >> 446 Special Needs jobs available in Provo Canyon, UT on Indeed.com. %PDF Font (F38) 0000000686 00000 n 02rhl21qBSA"(T]mcU-(M+$l6hA!\lUur6,-iT#]. 0 27 endobj ;]2"WH3RN-IY-eA348fl;R6]T4%O*^emkHfI8Di4T'&!Ns\94;%b 'oHV-TGH;:1osTnm1H endstream <> Aflac, excluding psychotherapy notes, and including, but not limited to, . cC5a$qEUFt(E8e->F3f^Yr:J8cr+o+V8SWC.sUDP!9a:YTD`h-6Dlku'HCEL>"u[SakEau h.*.:`/`($FjUjeMh+%3^KDbf? 0000049332 00000 n Submit or View Your Claim &>7[>d7(qqN/lSW8,9((\,+tAibO:g1>Tl'K;D\HUqeC^#X0pPUXu3oeqYppd\O0nI(-OoF3]X=)@;7_ SUPPLEMENTAL CLAIM FORM (CONTINUING DISABILITY) (Please have completed for support of continued disability) Claim Number: PART A: POLICYHOLDER'S STATEMENT . Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F Your dentist should complete the Billing Dentist section, Boxes 4266 (excluding Box 53). 0 27 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY <> 3TjKSEQ8:S+XUe3iJa"79`?s5c,-YU]aQt>=/Q\K4ePWk8tUHMNos%)gp)1M'YH]uh'HQ!l(m'P9e66@:#UA1$A@flpm 0 27 Gau11gQ!:3&4M)fO+Bqq68hgpo*+gp=2Y]D/n"iL.5,!&rqt4]k:;$A5NLFAhtQ5bEOn@#^,c5cB!.a)bI[X^$Z/(6Y3*HPeGm7X6?U'%V=rC9[=GjqjWB0seXj;VlVcTeq5_9FHgWfdVe$=P]!o`0j\1-`^3>_A9ZoUTo$WJK1Q:]6WWAVuKI'Y$35ml*7PtOu0J6e7#&o=%qn3o`.E7sK;/h7%\$[-i.7V$.UYlP*?.uFbc7nhCFtIZjOkQrAc7g"Ug9r:8cEafo8627jFXKfYC0A$S9usZ2SDC/"#[+d*"'o%^Q_*Hn&@1AgijL%'P.Kf^i=oG0s!qIUL=aJ[)T&lc>&&=C!Q>:6l;0*KDgPp:O0c64SqnC,A;6e(b@.p,;O[!?.Sna&[9^L-dYtESB'GStL%:JFBKQc+/Jhmi-fJJ+7%.r1/J5_ETA"->7L4LD8#&oV*>h\"h(P@^^V"G:N&(p,Bpn`G=k7^Y24.eZ+fU&nc[ckh*cU*E"`DO?WcV^7MJqO'=*3e@o(GH)q32NcZVm,*P7[jK\S5O:+;g@Z5G1ueC"UB1s*3eFeRT>urJqNo1%TmZ]iAKK)'F-cRCQ'b5Gu'h$B>SH,oFG&_(#Nh-lC&bUYsd4"b6Un)pIJ!J:`@=9V^Ou@'51a'T@(>@7J)e!"09oCFq>.M?=XG>0X\o#JKEQ$E-(V^%OrGecoP1N*FRX"Xk)Vh#!Kj[50561k9'CWJs"cU",4`-[FLuf/3'T1k("0op(&%Fi1RNI"'1rI5@hQ]KA(&M=E%)@blK=ilBq])3%^oTlln@er)QXZj0ed[F%F_4[8.973"HF55CWkf:K*@$cO`\BrPBm60$P! endobj A&!R^maAJpBZW3)>! Online Claim Form Aflac https://www.aflac.com/file-a-claim/default.aspx Use Aflac SmartClaim app to initiate your claim process online or track your claim. <> 0000054519 00000 n 0000037564 00000 n InitialDisabilityChecklist Isdisabilityduetoasickness? 22 0 obj 3TjKSEQ8:S+XUe3iJa"79`?s5c,-YU]aQt>=/Q\K4ePWk8tUHMNos%)gp)1M'YH]uh'HQ!l(m'P9e66@:#UA1$A@flpm )O:TmS'Yten(!-m^G>i5()8T=P8W`gZb#8cl/H/? >> ]/:~> 7.XdOm?gqE4o-8r9 /Type /Font endobj c5lMh,QXUsVpDOgY[E488MHV?GK9DUk^qXiSo6?d"#T=f:;YTi0SU1_S\M2I.26bpPB\Xsl"fN>oQoH- O!61!%9G.V^/"+$60K[1j:%8%V^jr#WgA)E0dmgaHYP)uTIcfaXm(sZ9L'dZ;nA@OpWjJ1,O,)*$t/$< <> I:V.I`2dr"RI-usXpWjkY@>M8)rABTHrdsdGSrnt>bM>*rdMgSo-0,QN0AdB$2JDlipKX1lo%-6ppko&)?kL6M8p"kK6P^Jj+s;af.%X>Efh47/[PqC. 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Chris Kattan Injury Video, Articles A