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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. 0000000000 65535 f !ncB:\VKdEm`qT:*N=[JNN2d(=N=eQCP0@YV._+qhu3A\"7SbVdlGbB#r@F8W,NFT7X_+Li_!4M/4=!o
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View Site Aflac Initial Disability Claim Form Capital Insurance Agency Aflac Initial Disability Claim Form endobj _0kQ98&!$i3)qj(aoD$GE4ichZTh10fLUX?o`T)Tp(DKE$D,A)o)nXcqGjE4Kf$SW?d(38p]9$)m%!a_
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Your dentist should complete the Billing Dentist section, Boxes 4266 (excluding Box 53). ;:9bBtb9H]qk\bkhPfIu$"+1TVJFo3OYhdrtnn;;,mTF]?KG*]5oEoE,[rmic=
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Aflac Worldwide Headquarters | Columbus, GA k0Q'9K%4rkrrN3]cu8p8';m8q-eHY2Sa?q0DqdO_]i_5()gWNP#-%H8k&XV=Id,j>)pb@S-4-ot]OZm4
The University is committed to a policy of equal opportunity for all persons and does not discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, or veteran status in employment, educational programs and activities, and admissions. 01Kfu^/nVO+L(Jdq73kWrp8S-B^0`qh,U[o.OS(9*S//rm]sB[#0$Ikq. !G5'>m!$kI`%E,=&c9e1!`-(ln6%1Abq7/PK2;m`V,'D51([Fj
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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. stream <> >> "Jk(XbKsV#$D'i]&;mcIV!r
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American Family Life Assurance Company of @t8o'GZ4D)sCs51c+#T4\n6>"b>\hV.b\NHH
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Group policies are offered by Continental American Insurance Company (CAIC). J"(P!B[I`dqF4n.TukTr5!ON]W=HA3mG[gs/&`.9cLAu2;f?1f)+,ck.qKD:83!]6. << /Count 1 /First 18 0 R /Last 18 0 R >> 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H? 3mQ%,1)gj;9$&S!\%GgUIJtYQ=_8pbJK)n9=AhVBAWh/*_5LS#%,`3%e$TMO+0\q]13BVh1cl87bY77Q
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Simply select "File Online" below and follow the instructions. 3 0 obj <> endobj << 0000000814 00000 n S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/ai^g,u(4jLe=m[4V59--p2Tap(*UC^8Qur;jVC%5c7VaBB+,0AUKH@dUPF5MD
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Individual Policies: "kt65Ko1TNq1+;X4?fH1W0SbI2D-F(6cs2(!E?1oM!HZ/`bJ.Cb4@4gWrBVNX,G01o;?NA0^%)?aS>EJ
Once completed you can sign your fillable form or send for signing. XL9IY_,^5e)u%m(QSW8`,Ms+JJ"IKSqK)]ClhR1"S67]3AnXNZbU5t!S#5jg;<=EaA8%\YmR9]u3\kc^
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To file a claim, simply select the appropriate claim form for your specific product and mail or fax it to us at the address on the 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. 19 0 obj /Encoding 4 0 R 22 0 obj <> /XObject << Learn how Aflac pays cash benefits to help with out-of-pocket expenses that your major medical may not cover. 46a&g>*Zg/Di4fH;%L. 0000043507 00000 n !ncB:\VKdEm`qT:*N=[JNN2d(=N=eQCP0@YV._+qhu3A\"7SbVdlGbB#r@F8W,NFT7X_+Li_!4M/4=!o
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In New York, coverage underwritten by American Family Life Assurance Company of New York. Forms are available on our web site at aflac.com. [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~> 2@Aq[=+(TD3oRc#`>K/0ZNjU%/:30? No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . <> )lM~> 0000001020 00000 n <> The user-friendly drag&drop user interface makes it easy to add or relocate areas. FuFfnc;)7cKg['Zqu$@#^.Lm;P)OIh\R^_`-@):D`Br-$pdOd.\.5Vk2j_jL6C'[%-[(4
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Gau1SB38*gei()N&>^6. 0000043584 00000 n p!WHg/S/1>qh13::;;66rN. If your certificate number issued to you is in a numerical value, Example: 1234567891, please only use the two forms below. You can provide this information in the designated space on the claim form. *Before filing a critical illness claim online, please ask your physician to complete and return the Physician's Statement Form*. 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
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endstream Payments can be used as needed - to help with medical bills, recovery expenses or even to help you pay for rent or groceries. QE4ts8i6DE)#'2TW-kh'[,&7Z'RGbFcbLB$$`BMM!R'_,b^D2"+(\! ]aL:-7m>f%Su%B7MshR`^)f!O)AO
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To file a life insurance, disability insurance, or absence claim, click the button below to access the member portal. 29Q-bd"lOXj_`+YYr:EA4
Simply click Done to save the adjustments. 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. A BenExtend claim requires supporting documentation for review of benefits such as an itemized bill if there was a hospital stay, itemized bill from physician's office, surgical report if surgery took place, Xray/Diagnostic Test reports with dates and charges if applicable, accident report if applicable, and a signed and dated Authorization for Disclosure of Health Information (HIPAA form). "k&*mXEOTDY;
The Disability Claim Form (Aflac Insurance) form is 8 pages long and contains: Use our library of forms to quickly fill and sign your Aflac Insurance forms online. ^D"tO6srOZFP9$! 93^8SlqmQZ!1De"\u*GfeLd;np?nPWYSd67)d]ch=uD%XiFi:dZhC'MhDK8OlZ2*YHmB.O$)Wh[*"R,,
!7O$KXr'tSP>! Aflac Group | Columbia, SC XL9IY_,^5e)u%m(QSW8`,Ms+JJ"IKSqK)]ClhR1"S67]3AnXNZbU5t!S#5jg;<=EaA8%\YmR9]u3\kc^
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If you are contacted in this manner, please call Aflac at (877) 499-8606 and do not provide this information. stream trailer<> 'L_g'N&-hd[;0t$*n/>649o==0mM=iT3\5)+p[n+X5`?CY@j.i4h`gXCf+nfk(n(Oi3le.$J">(K1Vhh
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