Aflac pdf claim form

Pdf accidenthospital indemnity wellness benefit claim. Your aflac policy provides one wellness benefit per policy year. Accident claim form failure to complete all sections may result in a delay in processing this claim. If disability, is later, determined to be for a longer term, there will be follow up forms required at that time. Claimantsignature familyrelationship,ifnotpolicyholder date page1of3 0708 cancer policynumber shorttermdisabilitysickness disabilityrider policynumber. Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementof. Your aflac new york policy provides one wellness benefit per covered person, per calendar year, and this. Continental american insurance company caic, a proud member of the aflac family of insurers, is a whollyowned subsidiary of aflac incorporated and underwrites group coverage. The values represent the average amount of claims paid to a policyholder with the condition over the timeframe 20072017. Aflac policies are not available in all states and may vary by state and plan level. Short term disability claim form instructions to avoid delays in processing of your claim form, complete each section attaching documentation below when it applies.

Aflac payout data shown is based on historical claims over a 10year period, across all product plans in force at the time. Several states require that the following statement appear on claim forms. Do not include receipts, statements or other documentation with this form. If your disability is being extended, you will need to complete the listed supplemental claim form. Please note that these benefits are not payable for. Download aflac short term disability claim form, also known as aflac initial disability claim form. Be certain to include all supporting documentation in your claim. Initialdisabilitychecklist isdisabilityduetoasickness. Do not include receipts, statements or other documentation. 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. To prevent delays, please provide documentation from your healthcare provider to support this claim. Aflac short term disability claim form initial disability. Hospital indemnity plan wellness benefit claim form failure to complete all sections may result in a delay in processing this claim.