Aflac pdf claim form

This form is for initial filing of a disability claim. Aflac short term disability claim form initial disability. Several states require that the following statement appear on claim forms. If disability, is later, determined to be for a longer term, there will be follow up forms required at that time. Do not include receipts, statements or other documentation with this form. Short term disability claim form instructions to avoid delays in processing of your claim form, complete each section attaching documentation below when it applies. Download aflac short term disability claim form, also known as aflac initial disability claim form. Our customer service representatives are here to assist you monday through friday from 8 a.

Initialdisabilitychecklist isdisabilityduetoasickness. If your disability is being extended, you will need to complete the listed supplemental claim form. Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementof. Your aflac policy provides one wellness benefit per policy year.

Aflac payout data shown is based on historical claims over a 10year period, across all product plans in force at the time. Any person who knowingly and with intent to defraud any insurance company, files a statement of claim containing any materially false, incomplete or misleading information, is guilty of crime. Aflac policies are not available in all states and may vary by state and plan level. Accident claim form instructions aflac group insurance. Accident claim form failure to complete all sections may result in a delay in processing this claim. Do not include receipts, statements or other documentation.

Aflac is not licensed to solicit business in new york, guam, puerto rico, or the virgin islands. Hospital indemnity plan wellness benefit claim form failure to complete all sections may result in a delay in processing this claim. This form is used to file a claim for short term disability. Accidenthospital indemnity wellness benefit claim form. The values represent the average amount of claims paid to a policyholder with the condition over the timeframe 20072017. Life claim forms for the state of illinois must be obtained by contacting aflac worldwide headquarters at 800. Pdf accidenthospital indemnity wellness benefit claim. Your aflac new york policy provides one wellness benefit per covered person, per calendar year, and this. Claimantsignature familyrelationship,ifnotpolicyholder date page1of3 0708 cancer policynumber shorttermdisabilitysickness disabilityrider policynumber. Please note that these benefits are not payable for. Be certain to include all supporting documentation in your claim.