0000001020 00000 n 0000000009 00000 n 0000054624 00000 n /I1 14 0 R /P0 15 0 R /P1 16 0 R /P2 17 0 R /Subtype /Type1 E7qKa,AgM_>47ek>g$eb0N? C)U\u?j:;&T7I/iGm[n\T;_)`gEYqdm*YLN@N-_eg4^hU\]H7Co2_+ugag&:Fd?U>McjOT-(PdfS7Ma7 <>stream endobj Had your Employer complete the Employer's Statement, and had it returned to you? 2"3sWA960?8;mmK#ZE2_=#C>QJ%q+@gg/`.\j'lY3GBQ_ecS2/`]F/b3$3maOCefRcJ`5!g@1,GaV\/9 If you are filing for disability, please complete the Initial Disability Claim Form (S00224). xref <> 25 0 obj 0000001422 00000 n 0JTM8HGN-uYUmTOelVf]F4AA)ZISHh>(!HVXe#12]a#X:Z;?uk$a0t'3>1o_N(G1e9TB>Kme4`U:>O6e Bk\1f/VUX4ST4NT40lN34+-*[pI_iW#ggd2*`hgWE^=-R:s=)2'tu01Vr]^_S>-&.RS7)o+'X@(Y83/( :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! "\1ceiPob[!+@J3(3TJ)YX)OUj[W9&;I:dYZ=kc)4eebY'g`kA>>[&O][obn/UEdfgRXrat28;.HM:HQa#NGoYVo#="o%! Create your eSignature and click Ok. Press Done. 25 0 obj State-paid family leave View more Life insurance View more Long-term disability insurance View more Short-term disability insurance View more Leave of absence View more Contact us 0000000446 00000 n endstream Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F If you are contacted in this manner, please call Aflac at (877) 499-8606 and do not provide this information. 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X3^f``c_A)\*/"78h!p%/*in2gI^?CblC`0:Dk,=U@Ip$RaFkC-A%5t[ObE/d?Sc8c!X5%k0qkA1$A(f A hospital indemnity claim requires supporting documentation for review of benefits, itemized bills showing medical treatment dates and diagnosed conditions, hospital admission and discharge papers for inpatient hospital admission and confinement benefits, pharmacy receipts for prescription drug reimbursement, and a signed and dated Authorization for Disclosure of Health Information (HIPAA form). 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY /2R!i5j&PBRjtAnemGT^T>r)/aH+##c99WL>k&k>=:> endobj m);lB2NZG/rMHahB@? ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d 11 0 obj 01Kfu^/nVO+L(Jdq73kWrp8S-B^0`qh,U[o.OS(9*S//rm]sB[#0$Ikq. @mT@XKG9gfV9sjgJ:!#'gnJe-hrK2RiqoM==]mG(t!Vd6O=URG3 >> TLFC\4aS)n5C^j*@4%"P0VVa9rj(. 0000003079 00000 n 0000049332 00000 n And the best part? Except in New York, individual insurance and group dental and vision insurance is offered by American Family Life Assurance Company of Columbus. 0000054923 00000 n endobj In NY both group and individual coverage is offered by American Family Life Assurance Company of New York. 0000055045 00000 n Administrative services are not insurance and are not considered legal advice. :0&HC(d$*r1.Y<=jD`$Ia7bVR3*X"Pd8ODQ(-pM4B8oHgR <> >> Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F [W_J1(2pZ1HC$V;V*/7\3N-"m8ACA6(\G4_j7tLZo4PDu:9kltQ:qtrOFJei`3u25)_cfnQ2M,M>*2Sb V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT Download the data file or print out your PDF version. /Title (New Claim Form PDFs for WEB - S00224) ?/8-TEfAU,j[:b-G[DjC57H"+$-Ag(@hZ InitialDisabilityChecklist Isdisabilityduetoasickness? -_6'A_4IL[`92un&r8tH[>^"rhOWrgJZC\%6"6'k2kR6&.9EYCGWVonkFA2[(WQ.mndG'-IoKK^(VM6j):K)HmcRL+qg#Rf TNMF9_Vr2,SFTeXfUSJa)jt-'"mb39a6fe"7:L*nQB6WHc=tGuKXhdlF@JojFLBR3CIdNL;Gs\omg&R3 . !$"P3qfbXDLeQ[oZ1B!OZ7r(l@ Business owner? /5&*Q)*,WjJn8+=I9EJW%)B]4Nh 0000040092 00000 n Gb"/,D/UE'&cO9g'Le5&-SP5UG1U(.gN&eaNpA_5Jen>pld`Ep3L8bprUnu0/pTC:L6'E&Oj6GD1q3j9aEcrf34m?(SYF9tiIC:9reE'%4hLa2A@q$X^Gul'8"j\_Z*Pnco=On_l;2u]$YT1JT1XNYZ$TWMcEU?(Ui>2@/K'qS2q=(qBpq<3n9RGEE0_8LAA>/$)9CPnE%+9ApaZ,q%!Z@U^=:+[a/uKS+%k1MN.5&^;J?&K;ie$ki31!T(>`p4Q/r^7M/gh:/g6\RiOpi02X8?9HDKNojiqH\fTkO*reW@;YqPcC9h-__*61?X3pEIK=-:Mg`CsmZsnd)H'+=n"uJWaI(c]kOWO`2UbM90f_0;rj"kWn=h4\6e+LchC?K(aad&A+d=lL_&TFbfmX0*Jd>>Lmhg']bd[,I"5X<0AA:^98ST=TL-W*EXj/?&T;_5X\sh.,]!.A7hkAL;K9,acI9;+t&)dF!#U9p7>)1ab(?k%('sei:-fSqGn8$875]6O?=iNSbFZPYbpfpi\fF=d!TWfO9_A*9i`E)g2nb9[]r6;B*+jn@3B*E8a.o&10@UPpd.#Fim\Qt3S_6srHr(cgA(HP-!=E1fm'jAS%[WEUY45$jA:1*!"_h4>,'ed0`:"U?a%>q5Sk8O%L5/-VbJOt%f[Wo5&+7ZWm)`Q\MtViQg@s#N?!#?+?55mL6n4[sHFW/%Oik>,,Q49TgBiiV=`lNki3%%cN37#n.#\jo&]u\b'SQXMkff2Z+:=E__ba,4,fbGl/%NfT1%mTOhR@Hp$eX`Q]NApHg(O!T!T,JX>YrfSc*XWe,tK-f@fjb!:P5SWnUq[raVb_pulJ5eg_;UrRuPp?]KMK'N[_*8]%m5lE/MnE-j/@_"piL`o$2b!5KmcMpl\QuKQe6cFt3d"QU/8VhMg61_(pFa[DgRo[/kl'*[iUgQtmpPAY@e=1ORRB\T@Y&ni:rb-NZ2i]/;Pbn)Ua2u6L(qd)ks=?'-P66*a*#!,#`\V:ShknH6?EG@*f;6o,.]tj+)KVD%`C'e%R(78-Y!,'>d7S46qeQgD:X.>@?&V#IDL,ZUABl.bFR0(2V)lAN)QF^Y:VNJGr,<0^9+mg(4kS?=%M/O;&RHQR.kY_:0U+3UiT0l;08h3,bP>Tsj5U^SoN_Cou8K3moS,"K9`Z`;s5*o9lCWSLVQ2bfj&klQ409JYQ.(1Jl'B%@9$i@pmb)GV`ANI^.?,OrNXq7rn!RPR*pKnG0";)$hnRY3Na_+4eo`l*Rf[7V7$BT;Hq&6m\*m^I>!#d$>&;?T+`ccsgY1q0]B[PIc;."8N4h08/D5'K7A*nV2KdGFWT"^SSIs:V1$^@,MDm-V,+oO6JtnX^/m[cEq`!?rH3`YI0cmWR"8g$/C/.+P\:)5[8jO$t!d\KSmXNOEr%:bg*AT5!?I0h75@nQ5rO)*(jd=kNcAd7$W=#YU)gJ_)^\D]!duA4Y#&>q6Wh!_O+IiRBMqDTm9H"-I'2m"XKZPJq?9=O95Od2JW(,0eXenP6H2L3)sWB\,I1e$uGg%):=Zg9it2S=Qa%FBIWcqqI$?UN5n=LFCbrrPG=QD4*5Zh.r,t?fL@e+`WG8)KnFiMJqn>N2aW.H/Rc*'uj0Ln97(H.aF2tMHd1M/o9KXDQHF9/UT9&QIUTI5Z82l?!=7]TLuX?-^'Ff"b^Z]e9-nn8_nN1:>j@91NTeBp%-W*,UW'0;Zs+%MsoCUq__]ahrQ_?>IQtA07A:.r4XV,T,mLf]ShS4914P3kYD^)KhQ:[^>JVT?pg*\ktXteM3K3s*[#Xa(ZV&cjs1Top:ClIhp]a[qR%]G^Xg)-Y?Sn.p8p=9Qk>UhQ6`jRmo3_uY(Q9Ma%Q'r/PbX`Wka@$F@Iut5SCH[:e%)nl;j]Ta@fK%i=_M>uWQ'2@?H;h8ar*=UOR,2o`fQu@+QH)K-piLh/a-J"&>^@kT996'GcZ1(8.2(tkUlu^Gupc7)bEOcBTBm"XLiL\0!$>_J7/I2=;%P5VulZgVP91SIms>4HT;9\Y5a_hi]denkL19?h/]=3eF=hVhIbn/++t$3W6].KQgAH_#eOk#HA7ZDGm>D'=T0pGhAA&F#'9L9GAB6!^R6WI!_BNY0Yg-kl%&U,+ic[XbJ)8hqNnKJ>-a`4LS>d^+JE>lKa#%)Xu?13'+ca'WIEAOd?Y6$MtOP1K``[PW*!2n[$qQI3]OSB^[OfBB!ijns;OJk#L^/:e0XaG+cKJ>&dt_VCu9jE^Kf?`Rt$Q^WKJI7c?2#D%4&i"5BA,\DhaPFbfHO&Y(E]r/[[6VNDn9*o+7*TbdQVpTNJP.4pbT=%Rf:]dN6bM+&god8d+B1,J;UNK-WBi)#Zuk8Hid\*WHp^BUXt$&_e"h%rWCICP'/ABL#24>X/e"*0oIS%1e)_V1%n.[J:%9?t/!G'Ti],DoOCBF]CA)YH+:,b.s(t1a)=hr]j8(f@EM;/b7l6(ai4c#LGHkL$o071#7)J9GY4gTVr#:'T=*QD_kt=`&9Cq_=Xd,Nke/#%!)34-M[ro998>9bnD/N>iqjE_\p0*BsnqTkiK_`6'DA?s.n7P3k)JPSQZG4D'G%h?8?%%HP@tr"8;u*u@73kB6`*9^G&jQ#K>MGcB5cQlXdqS^NjY3Id)%u/Sd5s^gcP&tT[f&Gn""Y^):oK,/\:NdSg@JJ?bRD7(3aKua`XgV;VRMfo2Ys9rhoL85bT%##/ff'Xl`^[P$5JLicJnrEsLEZ^]WLhGAXBOG3gc&1TR(CI]Ca2"In8:G)T)"VR(2!cO_.44"pNn$R>Zo"aD2\A*;KDHn/%A^Djt+U*T3?U=(9%UbRZ!L8E)t!"Q6+]#6^gmNh;-"l=lJRiRpdU:\_\\Ia=)Q6)V18ar)8JCkGq@N@3n*jg^&t_18^[Td/g^(=b)9.EXV/PU!nl,@SVbf[=QO0E4RVKB4.dh_cT;'?(l@*@Y`rN=H*e1/+7u]a,s#ITK7eqBO"[J0KCfX!mWFh6f0qf-pE]N5DCsG8I5<8WSngn$-cT-W^YT38)gM?-rCP^'-r0`Y&tsg_ncDO:%EN+k7;rH1j!k*2k!VrJrWEbHQQ?.%ajJ#`H!O7gE4I9_h>$Ai7O@>O;%0-$BNcRrmtbUb:u+Xb^g7:Y^bZp$i[K#[M;p_))3%#VZCou%b9;UBi>.srIrE3#D.'KLV$nt%#Wq6k)$U(b$o%5]TAbfR;9cgi#WVmE,aj8rTSdC.OGL1fCjOiC?d#HNPE<>gnjZnRrET1FM5h/Euj(#f9d")3O2'YqId"-U:*".(^\q101NEm#WAO5? To have your claims payment direct deposited, please download and fill out this Electronic Funds Transaction Authorization form. *WS>mdrX4a@K:\2X]Y(aJJnXSIKj37?5&F)>s:B7il/.16"r!2ThTJ5PA3j'f^*7d4SNu%N>--MA'!$L J"(P!B[I`dqF4n.TukTr5!ON]W=HA3mG[gs/&`.9cLAu2;f?1f)+,ck.qKD:83!]6. :b_AV)1V(ZcOZDX/m5A*jYG7Ls#=[g?T6ig2h"/>:-ToJWI)s^O ^f8SP@,%81kYF7&7>W`>g^5VpKEtLo)BHCQ9Z^%VoU(+& In CA, CAIC does business as Continental American Life Insurance Company (CAIC NAIC 71730) 0000054923 00000 n Claims are subject to policy terms and conditions. <>stream Quick steps to complete and e-sign Continuing disability claim form aflac online: Use Get Form or simply click on the template preview to open it in the editor. 0000000212 00000 n S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/, hE&QFc^dIdG#.H18:@0U,pbR1i0OHr%ZD%"dUD1"DuY4>c0PkmD1%2p#>4jE,*9"aVX9!`oVXR;d-Y3"Hq'?Sn=O;D/S!.>c4I`[@q^TH. rT)4FF1EPoVMN14>L,`\V:)bIb1npmugX^4,7NbhZ&&T,/8(>f=lM4?OnHSHRdi 3 0 obj ["`,abhS3LE"C=T6]&k%"Zl4BdN^JG3F!Y*CQe"Xqj- h.*.:`/`($FjUjeMh+%3^KDbf? endobj Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the, File a Hospital Indemnity via Fax or Mail, NY - Accelerated Death Benefit Claim Form, NY - Waiver of Premium Claim Form-Initial, NY - Waiver of Premium Claim Form-Permanent, NY - Convalescent Care Benefit Claim Form. 0000000326 00000 n (@(usgg(FDHdtq_aekmXE(BC6eG1C/8GXuO:=']]5O,*cYeJ6rL_T-&cqtYOG-PZ=N]XFkICN-m,r>>:_tp?- GtHt%Nh;7F1(!K[n[8/1g\PTUNaGT"=n\Bb:62T:Xt#[Q]!mJ,M&0#sD9($J$JR;eXA\0%6Xp-RXgTNJt5f^? 55184 8 0 obj %+7qEQTFU"'i_\(/=gq+JNS@%Y-$pZB>:Y4*(rCZfQj@Kgqq^GWEccM#up\R$:Ie]Cf@mqFQ&(pWqBMr <> endstream 3TjKSEQ8:S+XUe3iJa"79`?s5c,-YU]aQt>=/Q\K4ePWk8tUHMNos%)gp)1M'YH]uh'HQ!l(m'P9e66@:#UA1$A@flpm 2#Uk88j6F;!LPJCYg?_VnT>DO7>((M$tI28>B]"L9/3#3R1],d$6!$JJRKV2m(tG_Q]-T()Va>`2T]>l;eK>s(U,g-lu^? P\D=1Pt+K^bCr/L=R_+?]7:K8ND*^rZJ>\)+SO$sqSJ1VT+A'Q-ShdfdhK\Q%N%LoP*mTJ1U1["BmoP?0"U1GH. nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. eiE#q%9eO%886=-()4_+S4PR>Y.OpD>thDms)r(iY76&nF\4eSBh"@D8Ckg?OT/fVbq-a!hKg2P8WFKC*e*%O1YLY&R&=h#U$ A0Y5rjtc-l=mpq_h=;$=@msV1)_!YAgb[=l4d[#_f!$4lHeElf,p`grp.1a3BKs:! %PDF Font (F49) <> /XObject << Submit or View Your Claim DE.V"?h'jom'g4taZ=ggb[Rq9*%"D3_?>DBHcG"%EYhs\A)[02C%,[#:eC])1_\$c?cV\_3\d).P:QmEm*p#YH<04bhGCYr_BRigd-lMFY&qm3!U7+E'.29BdD[1$Xoi)[=&jM/3ntoZ9Yk9SnM:+ All forms are printable and downloadable. 0000000000 65535 f endobj h0cQ^!FY^@5YZ9`C((MZ9iSNHc>@i(/A6Ang=Q>29[%f,N\.ZX(j>Mqs0Q)QK[VqWr`O1c][Ae6 View details, map and photos of this single family property with 5 bedrooms and 3 total baths. *Jn&hZmHE?Eu$9%^_jrU\Fh>uH`k,8rK <> /Subtype /Type1 _!&bC^i_q2I9CB/*h:cD,Hkk1\kZS;m>SO1NsoNM4:]Q(C,@:h0A4BLsC9kO;JPmp4!e&.VVYRsQF:7"r\-8&/.I <> 26 0 obj << endobj ];]KtG'T^mQ6k\65n-CO3CpUj:9mE5T+QAa^Vn$W>6ZWQM=\_oAF,SBqE Use Fill to complete blank online AFLAC INSURANCE pdf forms for free. *#*-ScS*/MMA_!%)m!2N2g5V( &>7[>d7(qqN/lSW8,9((\,+tAibO:g1>Tl'K;D\HUqeC^#X0pPUXu3oeqYppd\O0nI(-OoF3]X=)@;7_ 0000000326 00000 n $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR 22 0 obj 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY Life claim forms for the state of Illinois must be obtained by contacting Aflac Worldwide Headquarters at 800.992.3522 to have the appropriate forms sent to you. )lM~> _^7`jFRJiik^>[sr;K_R=oP`RhjIDn7[PIg5,_,"obk"U42[,7b`:kTqB'Do)liYcA9l:=H+qjE). Choose your state of residence and select the appropriate form (s). *Before filing a critical illness claim online, please ask your physician to complete and return the Physician's Statement Form*. DCl*mJUg=pq^:YnVX2rH-?MoX;V+!pDt12?)+Ag/%cNZV^V$#m+E*A#TQr? p!WHg/S/1>qh13::;;66rN. 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Take advantage of the quick search and innovative cloud editor to create an accurate AFLAC Short Term Disability. ^f8SP@,%81kYF7&7>W`>g^5VpKEtLo)BHCQ9Z^%VoU(+& <>stream endstream "k&*mXEOTDY; GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. "k&*mXEOTDY; GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. 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). No Yes Isdisabilityduetoaninjury? 7.XdOm?gqE4o-8r9 >/FRGOB+OB[1iVR22-7Lnt@)K1T_gY[7;kiM;`1C&61:AoC42ST7*!-T+uZ3:t]s'Eh(_u3^02+HBBV< <> lPl9tY-IJ%_lFQbBP+,UB6!AO?&Q*kaBs. << V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT <> 0000030858 00000 n *WS>mdrX4a@K:\2X]Y(aJJnXSIKj37?5&F)>s:B7il/.16"r!2ThTJ5PA3j'f^*7d4SNu%N>--MA'!$L 0000055045 00000 n Z]9@&FL3T;C!WW4Ki3jpQoiR!f,B'&Z:-,IO-Zq$&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 )qT)jZA=U\YiCp>=mtH$[\__]9X3fUD/SEtnbat` Mail: Post Office Box 84075, Columbus, GA 31993, For critical illness claims, we need information from you and your attending physician. View Site Continuing Disability Claim Form Aflac https://api.aflac.com/docs/claimforms/S13270.pdf /I1 14 0 R /P0 15 0 R /P1 16 0 R /P2 17 0 R 0000000932 00000 n (V.ea8oM1meVG5&2$R&VHdRmbM`,/jQ'iTTlk_NLi7Pu8>hqB>F6,at#]$=1\UL'_o oJ!qE004N-XBk;7k]qo&bs<9Pm9 ]_h\LUlKWpDX[03gS"tG,UJ0*mL9UkEk%7OIX,#u6?P_/\,44Z>m2`cW$i)b*qRV/6raU^h/W^<6?6JC;$U>eK_"kZBZcu]&\dTh"\!Q%B8?1?Rk8,^p^Wn[RC5_%c^'XQF+or Please provide a certified copy of the deceased person's birth certificate and death certificate. -_6'A_4IL[`92un&r8tH[>^"rhOWrgJZC\%6"6'k2kR6&.9EYCGWVonkFA2[(WQ.mndG'-IoKK^(VM6j):K)HmcRL+qg#Rf ]_h\LUlKWpDX[03gS"tG,UJ0*mL9UkEk%7OIX,#u6?P_/\,44Z>m2`cW$i)b*qRV/6raU^h/W^<6?6JC;$U>eK_"kZBZcu]&\dTh"\!Q%B8?1?Rk8,^p^Wn[RC5_%c^'XQF+or (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!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%$(Vi!33gU7QS]rt"S4I%1~> endstream 3TjKSEQ8:S+XUe3iJa"79`?s5c,-YU]aQt>=/Q\K4ePWk8tUHMNos%)gp)1M'YH]uh'HQ!l(m'P9e66@:#UA1$A@flpm Connect whenever you need us. endobj #uY.o`Vd[Bd.YT[///3UJY[r*;n,NhjZnQjdJ7=`r$)Ri)3:i(@X2#3?N.HcWa:.*$kP? "tZ ["`,abhS3LE"C=T6]&k%"Zl4BdN^JG3F!Y*CQe"Xqj- IgeDH7TM\#pU10L#Ss`6=>>>RJf3(u"SS*/4)kIZjBeggFpXisbnT"]8aV=2.gG!O"):K$0*DuMhDAGnARk37 )toiFe(5W*JmS'IeRpMhRM\E^RfC)>n7:/sPgsY5E^.`.P>\/9SK;2 "D=hF9Hc;3b+uU#87#u->Oo&ZR/kmg`A@Va9ssE1`$L205UY2\m1KJ?'g1*p?gL[/Z6a.dV! ?&2QmV4C.$NuL;0P(Z7tk6M T9khijaBNZR9C,%t"7Fg@HCRo`)?gN`jH7$+&;F&1h$f-gZ@qpFS8g[qONg*?3muhSPi%q01m@ endstream ?NAW The Attending Physicians statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. You will be automatically redirected in 10 seconds or click the button below to be redirected immediately. 0000049332 00000 n There are three variants; a typed, drawn or uploaded signature. !$"P3qfbXDLeQ[oZ1B!OZ7r(l@ 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. 0000000686 00000 n endobj <>stream <> Then, follow the simple steps below to begin the claim process. )_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~> <> startxref 0000043584 00000 n 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$CLiNn/3c].L=V.c). ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R /2R!i5j&PBRjtAnemGT^T>r)/aH+##c99WL>k&k>=:> cC5a$qEUFt(E8e->F3f^Yr:J8cr+o+V8SWC.sUDP!9a:YTD`h-6Dlku'HCEL>"u[SakEau Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the Pre-Existing Investigation Statement. S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/ai^g,u(4jLe=m[4V59--p2Tap(*UC^8Qur;jVC%5c7VaBB+,0AUKH@dUPF5MD Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r 20 0 obj ?5QKLuXe>d/Imj )_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~> @mT@XKG9gfV9sjgJ:!#'gnJe-hrK2RiqoM==]mG(t!Vd6O=URG3 [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~> >> 0000054815 00000 n eokV:dNhZMi7O%JW^7S3)e7Na-0A!>>14!l. >> ]aL:-7m>f%Su%B7MshR`^)f!O)AO endobj jd*ZcXe"_QS4SaSM0H8\:kGm7EGchf:.,NK]?.0?7FYh&?aae5>4\THpn]0*9A8N 0000054815 00000 n %PDF Font (F38) (8p@RL@:%uhr=mo1Fg6rg/M;<4* For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York. 0000000563 00000 n c)$el$_7T'R>`H4d?VZZ.6:FXa^5[8hKt_jJ5`+n^Hma14HF`L'+tk,U=9slnfp8]Z?2MS[;()=`R FuFfnc;)7cKg['Zqu$@#^.Lm;P)OIh\R^_`-@):D`Br-$pdOd.\.5Vk2j_jL6C'[%-[(4 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! endobj (V.ea8oM1meVG5&2$R&VHdRmbM`,/jQ'iTTlk_NLi7Pu8>hqB>F6,at#]$=1\UL'_o (8p@RL@:%uhr=mo1Fg6rg/M;<4* endobj h0cQ^!FY^@5YZ9`C((MZ9iSNHc>@i(/A6Ang=Q>29[%f,N\.ZX(j>Mqs0Q)QK[VqWr`O1c][Ae6 endobj For critical illness claims, we need information from you and your attending physician. ;dps@dXdX$3sN65dLrqK;34,XZ>#G6k1;= <>stream 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). For step-by-step tutorials on filing an online claim, please see our claims checklists. 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