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Choose your state of residence and select the appropriate form (s). Payments can be used as needed - to help with medical bills, recovery expenses or even to help you pay for rent or groceries. 32h0$$08-8TYS-cMZH4Z@mV"tA/C(INdbs#Y3A\%VXCNMeOT)V?mHH\@]`s8D$dlP#B>-]=L]c3bUZ5nds%jlGpH>? nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. 0000037564 00000 n 0000001020 00000 n 19 0 obj 22 0 obj IsNhEk,PeVb^BZe[*I4rabcN&lDZ'ULHK+-T$;u]WD3GH('p*58J'[(3mgr(:*0TR2iG4M503dao>uU! YKROsZ>WYNLd_t?65*\J,Z?QVE?JeNB#Lrk^]8>,3&l. Z'qla+"Ni'F7cdihoHcj(u=..e%DbtGJWZF/nB*]I!`;q;hE9aN=iqM2-6r0A.0!kYlX,(D
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Have questions? 1g!5D-LsIWRBY-X(8X2r&@O_`0*:
[email protected]!Ja'h?grDR1Nq&[A-=2b! CAIC is not licensed to solicit business in New York, Guam, Puerto Rico or the Virgin Islands. View Site Aflac Initial Disability Claim Form Capital Insurance Agency Aflac Initial Disability Claim Form Dental and Vision plans are administered by Aflac Benefit Solutions, Inc.
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Your employer is responsible for providing the information in Part B, and your attending physician is responsible for providing the information in Part C. In addition, please read and then sign the Authorization for Disclosure of Health Information (HIPAA form) included in Part A, as well as the separate Authorization for Disclosure of Health Information (HIPAA form). 0000030858 00000 n Learn how Aflac pays cash benefits to help with out-of-pocket expenses that your major medical may not cover. endobj ;:9bBtb9H]qk\bkhPfIu$"+1TVJFo3OYhdrtnn;;,mTF]?KG*]5oEoE,[rmic=
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If the accident resulted from the use of a motor vehicle(s), a copy of the police or accident report is required. (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!AicdVn^"gp(^-oKqo#i"gBOsIn1fK.\PJgLt&^imq7BSJ..gu`g3TNp]lZQ:Q+PSQZ=7bSOhN`;B#7;s#7r)aO+XB?-BFdCkA(+.VnQp*5O$?iSK/`O.QJ'S)/aPDmhO:I1AIuZ^Ves%d@6'UQ5gRhf3BF`kXpaej\IRil\Y_Tp',^\5b3DiW.2X/9G,ZBZNQ1%0jnNTP=-/t4]pG5O*!$Hj%$(Vi!33gU7QS]rt"S4I%1~> c5lMh,QXUsVpDOgY[E488MHV?GK9DUk^qXiSo6?d"#T=f:;YTi0SU1_S\M2I.26bpPB\Xsl"fN>oQoH-
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<< ^D"tO6srOZFP9$! endobj CONTINENTAL AMERICAN INSURANCE COMPANY Post Office Box 84075 * Columbus, GA. 31993 Phone (800) 4333036 * - Fax (866) 849-2970 SHORT TERM DISABILITY CLAIM FORM *Please attach paperwork for any additional income you are receiving during this period of disability.
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Aflac Continuing Disability Form - Fill Out and Sign Printable PDF <> 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. We pay claims fast. Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r
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