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"tZ Offer your clients better benefit options with Aflac supplemental insurance policies. 0 27 )lM~> /Type /Font 26 0 obj 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). Please provide all the information requested in Part A of the initial claim form. 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Simply select "File Online" below and follow the instructions. endobj 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; 'X-2uc/>cM8\5p/T44i`BgV5"LY/5Yg% 7.XdOm?gqE4o-8r9 44EBCGZWK1$09&Q#o?-4-.oof+30H,2'QUFu;$7Pkc Manage your account, submit and track claims, setup direct deposit and more. $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR 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! "k&*mXEOTDY; This form may be used on all product claims except Group Term Life, Group Whole Life and AD&D claims. 0000054442 00000 n <> endstream 0000035380 00000 n (@(usgg(FDHdtq_aekmXE(BC6eG1C/8GXuO:=']]5O,*cYeJ6rL_T-&cqtYOG-PZ=N]XFkICN-m,r>>:_tp?- Simply click Done to save the adjustments. )O:TmS'Yten(!-m^G>i5()8T=P8W`gZb#8cl/H/? 0000037564 00000 n @oGDmsuR- )_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~> [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~> 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. 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Please provide all information requested on the Insured's Statement portion of the claim form. Get rid of the routine and create paperwork on the web! There are three variants; a typed, drawn or uploaded signature. GtHt%Nh;7F1(!K[n[8/1g\PTUNaGT"=n\Bb:62T:Xt#[Q]!mJ,M&0#sD9($J$JR;eXA\0%6Xp-RXgTNJt5f^? 0000000326 00000 n 14 0 obj 6 0 obj 0000037564 00000 n <> GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K >/FRGOB+OB[1iVR22-7Lnt@)K1T_gY[7;kiM;`1C&61:AoC42ST7*!-T+uZ3:t]s'Eh(_u3^02+HBBV< A0Y5rjtc-l=mpq_h=;$=@msV1)_!YAgb[=l4d[#_f!$4lHeElf,p`grp.1a3BKs:! /5&*Q)*,WjJn8+=I9EJW%)B]4Nh In NY, self-funded plans and absence services are administered by and insurance is offered by American Family Life Assurance Company of NY. <>stream endobj stream <> /XObject << 0000000446 00000 n N8EYJ/rdd(..BX8/1[!lhITlJFmO/CsZ%j/>QaJ13;:-PF0g J"(P!B[I`dqF4n.TukTr5!ON]W=HA3mG[gs/&`.9cLAu2;f?1f)+,ck.qKD:83!]6. "Jk(XbKsV#$D'i]&;mcIV!r p!WHg/S/1>qh13::;;66rN. Use the Cross or Check marks in the top toolbar to select your answers in the list boxes. !om"/\*lLc;1!=2VJY6B8M#SQkFA/PescpqBeho-)be]?.9:k-Uth]7P9'K8#,S=r#]\"XYE-i- <> Choose your state of residence and select the appropriate form(s). .mN(97.aR@?hUC/hmO_H@-r$8(#H,d[mojB7?G" c)$el$_7T'R>`H4d?VZZ.6:FXa^5[8hKt_jJ5`+n^Hma14HF`L'+tk,U=9slnfp8]Z?2MS[;()=`R Aflac Continuing Short Term Disability Claim Form Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf Please note: The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee's Form W-2. 0000054442 00000 n >> /Type /Font *Before filing a critical illness claim online, please ask your physician to complete and return the Physician's Statement Form*. trailer<> YKROsZ>WYNLd_t?65*\J,Z?QVE?JeNB#Lrk^]8>,3&l. 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Forms are available on our web site at aflac.com. Aflac Short-Term Disability Insurance pays cash benefits for covered disabilities (subject to exclusions and limitations). endstream CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. 0000001422 00000 n endobj endobj Dental and Vision plans are administered by Aflac Benefit Solutions, Inc. American Family Life Assurance Company of New York | Albany, NY 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; 02rhl21qBSA"(T]mcU-(M+$l6hA!\lUur6,-iT#]. endstream (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!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%$(Vi!33gU7QS]rt"S4I%1~> Upload the PDF you need to design. MLS# 1864249. File a Disability Claim File a Hospital Claim File a Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claim File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company Claim Aflac Group Insurance Additional Forms Authorization to Obtain Information Form Direct Deposit of Claims Payment Form Aflac Worldwide Headquarters | Columbus, GA )qT)jZA=U\YiCp>=mtH$[\__]9X3fUD/SEtnbat` Register now Aflac Life, Absence and Disability Solutions Learn more about. <> 0000035380 00000 n 0000049332 00000 n +-,&SN`[I-M6qW3;r1s0&Z$T=BbN][5p[;h9H7KL(+uC\p]Q8pinC7ha3-F4WH*,lCOr\XdV:L)GI3LX *#*-ScS*/MMA_!%)m!2N2g5V( R5BsS,N[X$9*1Su`V5!FLu53L/`5$Sl[7rqO,!^]g&GFP&S?ljI>6jN,bnDr8aF$lN\@CTOcGe"W!E$o FuFfnc;)7cKg['Zqu$@#^.Lm;P)OIh\R^_`-@):D`Br-$pdOd.\.5Vk2j_jL6C'[%-[(4 )qT)jZA=U\YiCp>=mtH$[\__]9X3fUD/SEtnbat` Aflac Group | Columbia, SC 0000054923 00000 n endstream GtHt%Nh;7F1(!K[n[8/1g\PTUNaGT"=n\Bb:62T:Xt#[Q]!mJ,M&0#sD9($J$JR;eXA\0%6Xp-RXgTNJt5f^? jPHFW8nlme]HU. 0000037564 00000 n (@(usgg(FDHdtq_aekmXE(BC6eG1C/8GXuO:=']]5O,*cYeJ6rL_T-&cqtYOG-PZ=N]XFkICN-m,r>>:_tp?- jd*ZcXe"_QS4SaSM0H8\:kGm7EGchf:.,NK]?.0?7FYh&?aae5>4\THpn]0*9A8N IsNhEk,PeVb^BZe[*I4rabcN&lDZ'ULHK+-T$;u]WD3GH('p*58J'[(3mgr(:*0TR2iG4M503dao>uU! 0000000000 65535 f 23 0 obj 0000000932 00000 n endstream . endstream endobj Take advantage of the quick search and innovative cloud editor to create an accurate AFLAC Short Term Disability. 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View details, map and photos of this duplex property with 4 bedrooms and 2 total baths. Please choose "Individual" or "Business.". <> _^7`jFRJiik^>[sr;K_R=oP`RhjIDn7[PIg5,_,"obk"U42[,7b`:kTqB'Do)liYcA9l:=H+qjE). Bk\1f/VUX4ST4NT40lN34+-*[pI_iW#ggd2*`hgWE^=-R:s=)2'tu01Vr]^_S>-&.RS7)o+'X@(Y83/( >> And the best part? U;s(7Es'Hq&:@a]^0oUGCJa3R7thK`//"XdS%5f,bl:[\>V0EGJX9:R[P$&(L2fO4E"!r*bnZA.0JbrSKY5@2H. ?&2QmV4C.$NuL;0P(Z7tk6M 0000054519 00000 n 0000055102 00000 n 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, File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company, Do Not Sell or Share My Personal Information. "-e/G/_P"pf.N+3cau8Z.,JJ6Rk;MRVJDs endobj 18 0 obj If your injury occurred on the job, a first report of injury filed with your employer must be attached to the completed claim form. 0000040092 00000 n If you are contacted in this manner, please call Aflac at (877) 499-8606 and do not provide this information. << Self-funded plans and absence services are administered by CAIC in all states but NY. ="8)^bHRPR0S#pBp\Hna_9-7K:diCtrB)_+K-\Z@W.j=Up^98J,Q-AtX6'$lc%D"gK+_Uc1u""HolR4)Hdg&NuR#8)Khmcol]#;]R+7)60eW.q/;.KZ6p49FV a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. 8*C9[J(Cl:;Gi9qfiditHQ#'L]jC2sPgd`'`W#[3J"LQg0%?W3t_5VRgmCJ5=M#ORRY\sAH6Rq;5+ChV$?jn,^o9SGo>Ha 3OKN&2W(XWj*4Pa1H50U%qWra$*VdVbd3"%Mqma1p?g8L8>2.+8'p^s14V/euOX@S5` 2@Aq[=+(TD3oRc#`>K/0ZNjU%/:30? m-*&@,H9g(2[5#o!G;R4U9IEG=[4#Wq9g71 "\1ceiPob[!+@J3(3TJ)YX)OUj[W9&;I:dYZ=kc)4eebY'g`kA>>[&O][obn/UEdfgRXrat28;.HM:HQa#NGoYVo#="o%! 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; 5]mS)I&\m'[NsCj]sr@0El\`]Uq+.S367pgfd2I2(=P['dU+EV"7XqK'c7K%if?fQ]VP endobj 15 0 obj AkJD?1M>up>BcsX+I=_#LC$k%qGLcEUfd4i%!i& 0000043507 00000 n ?f48_G,BN0p=/>&*)"gUTVU[Y>F[!H0S$cH]UJRYpFnh6'Ae"7a6i,,,Lbtk3(JMM]r0XUgZr>L@0I'i
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