For step-by-step tutorials on filing an online claim, please see our claims checklists. 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@;
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endobj endstream Aflac, excluding psychotherapy notes, and including, but not limited to, . Aflac Short-Term Disability Insurance pays cash benefits for covered disabilities (subject to exclusions and limitations). 25 0 obj A0Y5rjtc-l=mpq_h=;$=@msV1)_!YAgb[=l4d[#_f!$4lHeElf,p`grp.1a3BKs:! 0000043507 00000 n [P'])96k0r/j-O-5R.B+?Ujtp8t.Wa^\9uALh!R/l:Z3W3Fi9-eo;Q)?QN/coX1HH='4^
0000054519 00000 n /Length 310 Claimsmaybefaxedto1-877-44-AFLAC(1-877-442-3522) NY-S00224NY Page2of3 02/14 *LastName Suffix *FirstName MI *DateofBirth(mm/dd/yy) *Employee'sName(LastName,Suffix,FirstName,MI) *Employer'sName/Account# *Employer'sPhoneNumber INITIALDISABILITYCLAIMFORM-EMPLOYER'SSTATEMENT EMPLOYER'SSIGNATURE EMPLOYER'SPRINTEDNAME TITLE DIRECTPHONENUMBER DATE This form may be used on all product claims except Group Term Life, Group Whole Life and AD&D claims. 8,Y5:-bZ-;Z%c':c]*),@W=_c. #DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! trailer<> Bk\1f/VUX4ST4NT40lN34+-*[pI_iW#ggd2*`hgWE^=-R:s=)2'tu01Vr]^_S>-&.RS7)o+'X@(Y83/(
In New York, coverage underwritten by American Family Life Assurance Company of New York. 0000055102 00000 n endobj 21 0 obj 5 0 obj ]_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
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xref Aflac Claim Forms Initial Disability Claim Form Physician's Statement endobj X3$l$UUC.Q8bG%FB^qod-T(^7g7U9j!? :0&HC(d$*r1.Y<=jD`$Ia7bVR3*X"Pd8ODQ(-pM4B8oHgR
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). pVm0rYNePYi@2CrKlf(0`O9(:4lsA`"DB*V_2?OtI(:IK1s$SV]W0j\bo[2VhWP2Ff.O9.oYUrAMp$
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0000055102 00000 n If this is a Disability Product with your policy number beginning with AFL, please use the form below. a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. ;asisn+J&9Y*!/5
<> endobj 0000054923 00000 n lPl9tY-IJ%_lFQbBP+,UB6!AO?&Q*kaBs. Do Not Sell or Share My Personal Information. Gb"/l>AkOk&]_Z/^,64CCgQh(QQim(`'@6(M1VCS?Ymokm)Y?"923o3hrP9g4Yu*CcB6B*!?;6YT@s1*_r:*jjIVWN?8SPT[V>.M20U,P9l'4iI6TPY-]L!#f3%M(`,YCfUG&+3=,h@oh'%%R8_;#D97$7DPAU-\'4cMbSmaD1quDo:PhC8FAQ_/2XZE4Kg#d',UPm7ke>cGNcuWsA1Re6L<8TPh=9[*Pk3kf]HG?:]j+f^e0da8lF5rcV:E%B=r3G;%R(Xf":ZPhD;HI=o2=W1:skhAOSf)4$6[Y*hA_qQ>#XK+S'ZUkOIKD*iLBqMO1XS"!cLPYd()UE9Lm2lr6Mn03Uc=D9cmg9ZFLR'j#lTAS?p0fFMITB#ShK:pcr`bu\*p_7fncO=H:Cg))Dh,V>4bK>oW$PT7aee,0TKjD0nWW>XIsXWdMeY)H^W"J?KP[.,0T5VP[&"V-R*m\g;oH$Xg-3^E`2UO>b:S!S#%Ni>r1U>7W]WVl%FBJ6EJLK\e5S/p'%Rhg`ig(XQcq,`dM"Z"a`kcZ-'(jE_+^$?7s6^cGj474dI*df2J-e5q=Y_1b16H?P]03X?3K>qnsh^!G`9eSL__s6U1M*9Teo45)s'E#TeBH)kV0Og)S^AO+J(2F[da5RA>ICW7:^P&t'LLAnd0HKr&IpsIn8SeU(:Jc=*pS?k-99YCErn>UJX-`Hn%(aqln*&$XIcANS4VpU[QLj]G!;#@EAKq^@j,u;`/,(/Na!g5q"Yh65\"D,!aB.Em\'n/8"7*<31JeCqa`mMJ:h^-@Y+&*%Hi'pHjq[(V+Huac?`=P/n;ZtVYhK&jU4+P;,;Li0RY7*b9.,B=i>Eeq&&>XEt+0g%csST^gUX`O)f4L?@mpN=*2KGID@n!ahWqW<0.bbeua0:q(o7]2r0OVPUZgknmZaeqoclXGYUp'!2bS=sHp[\G[PG!Smtge^H`:p@^73,cnK$pco"N52fZ7k,?t_TBa6[Yo38a*bPjO'L>&jO>C.hg#O#*qQR%MfmPB/pb=.ds3hbk[@d1B`!QLOun.$sgs3XfN'9kHM]j^-B:=S5hBb`)3Y[+?"%4"O*G7.WL:[M7VEor0!>;%F[GQFZUW-817ADTaR](EM)4B>C4br^N)Q@KkkpNbQ$O`Ai!OQG#u9I'pD\EjH. All forms are printable and downloadable. endobj 0000055102 00000 n 44EBCGZWK1$09&Q#o?-4-.oof+30H,2'QUFu;$7Pkc
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16 0 obj Gau1SB38*gei()N&>^6. Learn how Aflac pays cash benefits to help with out-of-pocket expenses that your major medical may not cover. TJ(bq:!Ce_pc=2B1P"%7$HG=ui[FCuL+*6":'=rM2is:GPB$q%ZHU@,+FueOi0ob+.\6Ek;q7r%XbW$S
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0000000212 00000 n . endobj <> 0000055102 00000 n 0000040092 00000 n . 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%Q-/:EP^K/u*2f#eWVR['(Z7F!QM(!m?U.3>lak?8[tRmj?FN/_d2^MMq-[cT:Gp[D^&q<0d#8`Q3))
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>> Group policies are offered by Continental American Insurance Company (CAIC). ^D"tO6srOZFP9$! 0000000814 00000 n 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H? 0000001422 00000 n TiH!-bXfof5[n@&[kS/JgZ:HFlTDHBWer?faRZL
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Please submit the pathology report used in the diagnosis of a malignant cancer, the claimant's birth certificate, and any itemized medical bills with the diagnosis and procedure codes, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). Connect whenever you need us. If your disability is being extended, you will need to complete the listed Supplemental Claim form. /Encoding 4 0 R jPHFW8nlme]HU. 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY
Manage your account, submit and track claims, setup direct deposit and more. -8KU)@AZCLegJ8ge%BBp0g(_Y&;BmiFJfS%>@Gu7. 25 0 obj ]/:~>
0 27 We built our online claims process to save you time and to help give you peace of mind. 3OKN&2W(XWj*4Pa1H50U%qWra$*VdVbd3"%Mqma1p?g8L8>2.+8'p^s14V/euOX@S5`
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<> . CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. ?5QKLuXe>d/Imj
GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. Aflac lets you provide your employees with outstanding benefits without costing you a penny. If you are filing for a health screening on your Hospital Indemnity, Accident, or Critical Illness plan for Coronavirus (COVID-19) testing, select Biometric Screening as your exam. << /Count 1 /First 18 0 R /Last 18 0 R >> <> 1 0 obj 0000040092 00000 n Gau11gQ!:3&4M)fO+Bqq68hgpo*+gp=2Y]D/n"iL.5,!&rqt4]k:;$A5NLFAhtQ5bEOn@#^,c5cB!.a)bI[X^$Z/(6Y3*HPeGm7X6?U'%V=rC9[=GjqjWB0seXj;VlVcTeq5_9FHgWfdVe$=P]!o`0j\1-`^3>_A9ZoUTo$WJK1Q:]6WWAVuKI'Y$35ml*7PtOu0J6e7#&o=%qn3o`.E7sK;/h7%\$[-i.7V$.UYlP*?.uFbc7nhCFtIZjOkQrAc7g"Ug9r:8cEafo8627jFXKfYC0A$S9usZ2SDC/"#[+d*"'o%^Q_*Hn&@1AgijL%'P.Kf^i=oG0s!qIUL=aJ[)T&lc>&&=C!Q>:6l;0*KDgPp:O0c64SqnC,A;6e(b@.p,;O[!?.Sna&[9^L-dYtESB'GStL%:JFBKQc+/Jhmi-fJJ+7%.r1/J5_ETA"->7L4LD8#&oV*>h\"h(P@^^V"G:N&(p,Bpn`G=k7^Y24.eZ+fU&nc[ckh*cU*E"`DO?WcV^7MJqO'=*3e@o(GH)q32NcZVm,*P7[jK\S5O:+;g@Z5G1ueC"UB1s*3eFeRT>urJqNo1%TmZ]iAKK)'F-cRCQ'b5Gu'h$B>SH,oFG&_(#Nh-lC&bUYsd4"b6Un)pIJ!J:`@=9V^Ou@'51a'T@(>@7J)e!"09oCFq>.M?=XG>0X\o#JKEQ$E-(V^%OrGecoP1N*FRX"Xk)Vh#!Kj[50561k9'CWJs"cU",4`-[FLuf/3'T1k("0op(&%Fi1RNI"'1rI5@hQ]KA(&M=E%)@blK=ilBq])3%^oTlln@er)QXZj0ed[F%F_4[8.973"HF55CWkf:K*@$cO`\BrPBm60$P! ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R
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