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Please date and sign all required forms where indicated. 'oHV-TGH;:1osTnm1H
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Offer your clients better benefit options with Aflac supplemental insurance policies. 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. ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R
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#uY.o`Vd[Bd.YT[///3UJY[r*;n,NhjZnQjdJ7=`r$)Ri)3:i(@X2#3?N.HcWa:.*$kP? We pay claims fast. 0000054923 00000 n Get filing requirements, supporting documentation details, and more. 11 0 obj >> View Site Aflac Initial Disability Claim Form Capital Insurance Agency Aflac Initial Disability Claim Form 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY
Please provide all information requested on the Insured's Statement portion of the claim form. FuFfnc;)7cKg['Zqu$@#^.Lm;P)OIh\R^_`-@):D`Br-$pdOd.\.5Vk2j_jL6C'[%-[(4
InitialDisabilityChecklist Isdisabilityduetoasickness? endstream If you disagree with a claims decision, you may submit an appeal citing supporting policy provisions. 5 0 obj Please complete the Patient section, Boxes 818, as well as the Policyholder/Employee section (excluding Boxes 3138 and 40.) ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(;
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Form # 1015 Disability Claim Filing Instructions Have you 1. "-e/G/_P"pf.N+3cau8Z.,JJ6Rk;MRVJDs
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Create your eSignature and click Ok. Press Done. mhQCujn[DM`k5Vu9TL8/lY,n@)69`YnLctGSmP1C9g-Y\7nk0=`m#b/(aquK(k!OU2OhA)L%au^_^KfM
/Type /Font Administrative services are not insurance and are not considered legal advice. 1;O*2,G$@I\"rb]Q.4D=II@4)^=0+TVqO'Vmr2I;^-/4+)F;?jKG:nrWIe,-on%\in1XBefUaLD^%V#'74qV#Ctu(;N)%J
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For groups sitused in California, group coverage is underwritten by Continental American Life Insurance Company. V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT
<> Dental and Vision plans are administered by Aflac Benefit Solutions, Inc. Yku1YRdk^9;TD\;*kl4jYjTa8Xl"SC:fUS)e;!AcrDK#l16`LFaGhEJ;`,G>'H*8^Jr\^>/E?FZ]1S?b
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If you are filing for a health screening on your Hospital Indemnity, Accident, or Critical Illness plan for Coronavirus (COVID-19) testing, select Biometric Screening as your exam. 0000000326 00000 n endobj <> endstream The Attending Physicians statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. /Encoding 4 0 R I:V.I`2dr"RI-usXpWjkY@>M8)rABTHrdsdGSrnt>bM>*rdMgSo-0,QN0AdB$2JDlipKX1lo%-6ppko&)?kL6M8p"kK6P^Jj+s;af.%X>Efh47/[PqC. 3TjKSEQ8:S+XUe3iJa"79`?s5c,-YU]aQt>=/Q\K4ePWk8tUHMNos%)gp)1M'YH]uh'HQ!l(m'P9e66@:#UA1$A@flpm
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