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<>stream Please provide all information requested on the Insured's Statement portion of the claim form. endobj 18 0 obj 0 27 >> stream 02rhl21qBSA"(T]mcU-(M+$l6hA!\lUur6,-iT#]. ];]KtG'T^mQ6k\65n-CO3CpUj:9mE5T+QAa^Vn$W>6ZWQM=\_oAF,SBqE
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>> xref In NY both group and individual coverage is offered by American Family Life Assurance Company of New York. eokV:dNhZMi7O%JW^7S3)e7Na-0A!>>14!l. Log in to to your account or Chat with us. R5BsS,N[X$9*1Su`V5!FLu53L/`5$Sl[7rqO,!^]g&GFP&S?ljI>6jN,bnDr8aF$lN\@CTOcGe"W!E$o
lPl9tY-IJ%_lFQbBP+,UB6!AO?&Q*kaBs. The user-friendly drag&drop user interface makes it easy to add or relocate areas. If you are contacted in this manner, please call Aflac at (877) 499-8606 and do not provide this information. 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. QE4ts8i6DE)#'2TW-kh'[,&7Z'RGbFcbLB$$`BMM!R'_,b^D2"+(\! <> mOu72$0Z_TEkhh3=;Da@gQ!"PXflT9`-nbs>;ZjA5? /Filter [/ASCII85Decode /FlateDecode] 9srK>"cZ(SQ7f&_@XkjoOD9.JoV5["B)lrLk1"RN#NAQ@Io/k:h_VaFk%A]Xes%eU0Lr%f7V@nha@^3[
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File a Disability Claim File a Hospital Claim File a Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claim File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company Claim Aflac Group Insurance Additional Forms Authorization to Obtain Information Form Direct Deposit of Claims Payment Form health plan (including CAIC or Aflac, with respect to other CAIC or Aflac coverages) or health care clearinghouse that has any records or knowledge about me. ?5QKLuXe>d/Imj
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Aflac is here to help. :^_n)prV#UtcF7_C)h7^7
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0000000932 00000 n Mail: Post Office Box 84075, Columbus, GA 31993, For critical illness claims, we need information from you and your attending physician. xref 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). 0000000000 65535 f endobj nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). 26 0 obj 8e==QcdnYk8&(`lkD;,]b;+SbfrO-.*]B,RLFCV[]Pa\Z? m-*&@,H9g(2[5#o!G;R4U9IEG=[4#Wq9g71
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File a Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claim, File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company Claim, File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company, Do Not Sell or Share My Personal Information. Aflac Group | Columbia, SC 0000003079 00000 n <> 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY
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16 0 obj <> 24 0 obj a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. 0000040092 00000 n If your injury occurred on the job, a first report of injury filed with your employer must be attached to the completed claim form. >> ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R
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endobj We pay claims fast. 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H?