Accident wellness benefit claim form instructions please use. Accident wellness benefit claim form instructions please use black or blue ink only and print legibly when completing this form in its entirety. When you use aflac smartclaim to submit accident, cancer, hospitalization or illness claims online youll get paid fast. Aflac printable claim forms fill out and sign printable pdf. To prevent delays, please provide documentation from your healthcare provider to support this claim. If disability, is later, determined to be for a longer term, there will be follow up forms required at that time.
Incomplete forms cannot be processed and will be returned. Please complete all sections of the form, sign, date, and mail form to the address shown below. Accidenthospital indemnity wellness benefit claim form. American family life assurance company of columbus aflac attn. Aflac accident hospital indemnity wellness benefit claim form. The advanced tools of the editor will direct you through the editable pdf template.
Each additional treatment date should be on a separate claim form. S00198ca failure to complete this form in its entirety may result in a delay in processing this claim. American family life assurance company of columbus aflac worldwide headquarters 1932 wynnton road columbus, georgia 31999 1. Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementof. Continental american insurance company caic, a proud member of the aflac family of insurers, is a whollyowned subsidiary of aflac incorporated and. Sign, date, and mail or fax the completed form to the addressnumber shown below. Claiming insurance is a much descriptive task, where you have to describe many details about your. This form is what you would use in the event of injury from an accident or it may be used if you have benefits that cover wellness procedures such as mammograms or pap smears. My revocation must be submitted in writing to aflac, attn.
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. If you are interested in filing your claim online or uploading documentation on an existing claim, register. Was this a motor vehicle accident in which the patient was the driver. Claims department worldwide headquarters 1932 wynnton road columbus, ga 31999 for information or help filing your claim, please call tollfree 180099aflac 18009923522 or visit our web site at.
Aflac short term disability claim form initial disability. Wellness and health screening claim form failure to. Pdf accident wellness benefit claim form aflac group insurance. Fill out, securely sign, print or email your aflac accident claim form cooper farms instantly with signnow. In order for your claim to be expedited, we need all the requested information at time of claim. Claims department worldwide headquarters 1932 wynnton road columbus, ga 31999 for information or help filing.
Accidental injury claim form failure to complete this form in its entirety may result in a delay in processing this claim. For information or help filing your claim, please call tollfree 180099 aflac 18009923522 or visit our web site at aflac. Benefits are payable to you unless we receive written authorization from your provider to assign benefits to them or from you to pay your benefits elsewhere. Please complete all sections, sign and date, then mail or fax this form with the following information to the contact information at top right. This form is what you would use in the event of injury from an accident or it may be used if you have benefits that cover wellness procedures such as. You understand and agree that aflac may update these terms from time to time by posting revised terms on this page.
Download aflac accident wellness benefit claim form pdf. Aflac is a voluntary benefit policy that is paid entirely by the employee. Accident claim form failure to complete all sections may result in a delay in processing this claim. Please submit the pathology report used in the diagnosis of a malignant cancer, the claimants birth certificate, and any itemized medical bills with the diagnosis and. Download aflac short term disability claim form, also known as aflac initial disability claim form. Aflac accident hospital indemnity wellness benefit claim. Start a free trial now to save yourself time and money. Thank you for trusting aflac with your hospital indemnity needs. And since we can process your claim quickly, aflac helps give you the peace of mind knowing you can spend more time recovering and less time worrying about bills. Pdf accidenthospital indemnity wellness benefit claim form. American family life assurance company of new york aflac new york. Download the aflac short term disability claim form pdf.
Failure to follow these instructions will delay the processing of your claim. Failure to complete all sections may result in a delay in processing this claim. Complete policyholderpatient information and sign your claim form. Aflac printable claim forms esign pdf with electronic. For information or help filing your claim, please call tollfree 180099aflac 18009923522 or visit.
Be sure to sign your claim form at the bottom of page 1. Claims department worldwide headquarters 1932 wynnton road. If disability, is later, determined to be for a longer. Life claim forms for the state of illinois must be obtained by contacting aflac worldwide headquarters at 800. To prevent delays, please provide documentation from your.
When you use aflac smartclaim to submit accident, cancer, hospitalization or illness claims online by 3 p. This form is used to file a claim for short term disability. The aflac claim form is a form deigned to use when you are going to claim your aflac insurance. Failure to complete this form in its entirety may result in a delay in processing this claim. Some of the tests listed may not be covered under the wellness benefit of your policy.
Your aflac new york policy provides one wellness benefit per covered person, per calendar year, and this. Was this injury caused by an incident that occurred while performing the duties of hisher employment. Cancer claim form physicians statement american family life assurance company of columbus aflac attention. Keep a copy of the supporting documentation and this completed form for your records. Keep a copy of the supporting documentation and this. For information or help filing your claim, please call tollfree 180099aflac 18009923522 or visit our web site at tollfree fax number 187744aflac 18774423522 any person who. Accident wellness benefit claim form do not write on form except as instructed. Policyholder signature printed name date date of physicians visit. Claiming insurance is a much descriptive task, where you have to describe many details about your disease, disability, illness or accident etc. Aflac is not licensed to solicit business in new york, guam, puerto rico, or the virgin islands. The claim cannot be processed until all necessary information is provided.
Wellness and health screening claim form failure to complete. S2029ca american family life assurance company of columbus aflac. To help provide relief for puerto rico policyholders affected by earthquakes, aflac will defer premium payments coming due for. Do not attach receipts, statements or other documentation to this form. The most secure digital platform to get legally binding. Please use black or blue ink only and print legibly when completing this form in its entirety. To help provide relief for puerto rico policyholders affected by earthquakes, aflac will defer premium payments coming due for affected policyholders, starting december 28, 2019, and ending march 9, 2020. Hence, the form is also a lengthy one, and contains many fields to accumulate all necessary details. If you are interested in filing your claim online or uploading. Mark only wellness exam boxes for tests that you had. American family life assurance company of columbus aflac attention.
The facts say you need the protection of the aflac accident advantage insurance policy. Bills for treatment of this accident along with any accident reports. Claimantsignature familyrelationship,ifnotpolicyholder date page1of3 0708 cancer policynumber shorttermdisabilitysickness disabilityrider policynumber. Accident wellness benefit claim form failure to complete all sections may result in a delay in processing this claim. The way to complete the online aflac accident hospital indemnity wellness benefit claim form on the internet. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. Pdf accidenthospital indemnity wellness benefit claim.
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