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46a&g>*Zg/Di4fH;%L. Had your Employer complete the Employer's Statement, and had it returned to you? Short Term Disability/Long Term Disability Claim Form. 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$Xoi)[=&jM/3ntoZ9Yk9SnM:+
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<> endobj Choose your state of residence and select the appropriate form(s). 5]mS)I&\m'[NsCj]sr@0El\`]Uq+.S367pgfd2I2(=P['dU+EV"7XqK'c7K%if?fQ]VP
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endobj 0000000686 00000 n endobj <> Explore the unlimited potential and flexibility that comes with the opportunity to become an Aflac insurance agent. /Type /Encoding Read, signed and dated the Authorization for Release of Information? (@(usgg(FDHdtq_aekmXE(BC6eG1C/8GXuO:=']]5O,*cYeJ6rL_T-&cqtYOG-PZ=N]XFkICN-m,r>>:_tp?-
A0Y5rjtc-l=mpq_h=;$=@msV1)_!YAgb[=l4d[#_f!$4lHeElf,p`grp.1a3BKs:! Aflac Sickness Claim Form Physician's Statement 25 0 obj p!WHg/S/1>qh13::;;66rN. 55184 Offer your clients better benefit options with Aflac supplemental insurance policies. 3mQ%,1)gj;9$&S!\%GgUIJtYQ=_8pbJK)n9=AhVBAWh/*_5LS#%,`3%e$TMO+0\q]13BVh1cl87bY77Q
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To file a life insurance, disability insurance, or absence claim, click the button below to access the member portal. 0000000446 00000 n @oGDmsuR-
55184 endobj Send it in to: PO Box 60676, Worcester, MA 01606, Long Term Care/Home Health Care Benefit Claim Form, Automatic Bank Draft/Electronic Funds Transfer, New York Domestic Violence Notice (For Life Insurance Policyholders). View Site Continuing Disability Claim Form Aflac https://api.aflac.com/docs/claimforms/S13270.pdf IsNhEk,PeVb^BZe[*I4rabcN&lDZ'ULHK+-T$;u]WD3GH('p*58J'[(3mgr(:*0TR2iG4M503dao>uU! GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. << Aflac Group | Columbia, SC <> /XObject << 01Kfu^/nVO+L(Jdq73kWrp8S-B^0`qh,U[o.OS(9*S//rm]sB[#0$Ikq. _^7`jFRJiik^>[sr;K_R=oP`RhjIDn7[PIg5,_,"obk"U42[,7b`:kTqB'Do)liYcA9l:=H+qjE). )O:TmS'Yten(!-m^G>i5()8T=P8W`gZb#8cl/H/? Z]9@&FL3T;C!WW4Ki3jpQoiR!f,B'&Z:-,IO-Zq$&hBkC=HU@Y3)-Z7i/#[6S/+p@I:RnZ,Zu8hna5,OXLi#hGpMO`^lS.s0&6Us=%m@8h6<5u9e[1qBDSkRo7:L?^bDtpRqeOlX:eqkU9[p,&in^ADo=rk`A*eP:sf'8Vn
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Get Aflac Continuing Disability Form - US Legal Forms health plan (including CAIC or Aflac, with respect to other CAIC or Aflac coverages) or health care clearinghouse that has any records or knowledge about me. Please provide all information requested on the Insured's Statement portion of the claim form. For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York. 24 0 obj 0000054442 00000 n << nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. 0000055102 00000 n 2@Aq[=+(TD3oRc#`>K/0ZNjU%/:30? <>stream endobj Check if everything is filled in correctly, with no typos or lacking blocks. )lM~> /I1 14 0 R /P0 15 0 R /P1 16 0 R /P2 17 0 R 0000003079 00000 n 8,Y5:-bZ-;Z%c':c]*),@W=_c. endobj endstream Your employer is responsible for providing the information in Part B, and your attending physician is responsible for providing the information in Part C. In addition, please read and then sign the Authorization for Disclosure of Health Information (HIPAA form) included in Part A, as well as the separate Authorization for Disclosure of Health Information (HIPAA form). startxref 0000055102 00000 n ^$F!_M^D.n0(qARn(aE/AgY,iIM9"8CcNDqjSN*8m)"S@.f==Xc1]GcbA-_LZ\:A:pe2tj
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We pay claims fast. 0000001020 00000 n 16 0 obj 29Q-bd"lOXj_`+YYr:EA4
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To have your claims payment direct deposited, please download and fill out this Electronic Funds Transaction Authorization form. XL9IY_,^5e)u%m(QSW8`,Ms+JJ"IKSqK)]ClhR1"S67]3AnXNZbU5t!S#5jg;<=EaA8%\YmR9]u3\kc^
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If you were first treated in an emergency room, a copy of the hospital discharge papers is required to verify the first date of treatment, diagnosis, and procedure. The Attending Physicians statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. Direct to Consumer individual coverage underwritten by Tier One Insurance Company. (8p@RL@:%uhr=mo1Fg6rg/M;<4*
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