:JP2npQHaeod^X7'sK!^CIY561O?2S)MJ3_5]Y=4,Cn7b%K5Me(p[?9MOo\lj=] endobj 0000055045 00000 n If you are contacted in this manner, please call Aflac at (877) 499-8606 and do not provide this information. 0000000563 00000 n :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! endstream 55184 0000000212 00000 n The user-friendly drag&drop user interface makes it easy to add or relocate areas. 15 0 obj /BaseFont /Times-Roman !G5'>m!$kI`%E,=&c9e1!`-(ln6%1Abq7/PK2;m`V,'D51([Fj 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. 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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$"+1TVJFo3OYhdrtnn;;,mTF]?KG*]5oEoE,[rmic= ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d <>stream endobj endobj qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib 16 0 obj <>stream 19 0 obj 22 0 obj #DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! I)%]TcA`mWhX>Fb(1P"hjhfpCIF@eR>[8Uk8jb3JJCK>D0o*mhlN*%U(90mDYL0F##rb&>4GjbSZj8#' If the accident resulted from the use of a motor vehicle(s), a copy of the police or accident report is required. 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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). trailer<> <> 0000000563 00000 n endstream 0000049255 00000 n endobj Do Not Sell or Share My Personal Information. 20 0 obj endobj * <> `JaOS[A]]e$%M7QS4Qo!meJ)_CS:m7V7-aS4FZ1PGi:"6tO9;>TbWc_tC3LGp( 5 0 obj k0Q'9K%4rkrrN3]cu8p8';m8q-eHY2Sa?q0DqdO_]i_5()gWNP#-%H8k&XV=Id,j>)pb@S-4-ot]OZm4 #uY.o`Vd[Bd.YT[///3UJY[r*;n,NhjZnQjdJ7=`r$)Ri)3:i(@X2#3?N.HcWa:.*$kP? 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY e(d`r+1(IK_Z9J8FZEKhh]p"mOP2o\*_i:B,oR:q;pr&)1JfnGrF_2WN1&RdVP7b@X=`\9QI&,k/0N4e 4)&nf$tE5"g*2#E``6gl3H_U)RH)m.VU*-AYq=+#%i9Y7;)=6rhbKN=8id"8PGV#c1SW%K9D-r,8`1lZ << ^D"tO6srOZFP9$! endobj CONTINENTAL AMERICAN INSURANCE COMPANY Post Office Box 84075 * Columbus, GA. 31993 Phone (800) 4333036 * - Fax (866) 849-2970 SHORT TERM DISABILITY CLAIM FORM *Please attach paperwork for any additional income you are receiving during this period of disability. PDF New Claim Form PDFs for WEB - S00224 - Aflac endobj 8 0 obj 17 0 obj endobj [W_J1(2pZ1HC$V;V*/7\3N-"m8ACA6(\G4_j7tLZo4PDu:9kltQ:qtrOFJei`3u25)_cfnQ2M,M>*2Sb 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 ;An6Y?l:#h=mlN1\Er 0000043584 00000 n . CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. Please provide all information requested on the Insured's Statement portion of the claim form. Submit your claim online 24/7 Manage your account, submit and track claims, setup direct deposit and more. POije23\6G%qCTitHV>Xor, Consider filing online for faster claims payment! (V.ea8oM1meVG5&2$R&VHdRmbM`,/jQ'iTTlk_NLi7Pu8>hqB>F6,at#]$=1\UL'_o ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R (8p@RL@:%uhr=mo1Fg6rg/M;<4* Filing Claims | Aflac Group <> 55184 endobj 'X-2uc/>cM8\5p/T44i`BgV5"LY/5Yg% 'L_g'N&-hd[;0t$*n/>649o==0mM=iT3\5)+p[n+X5`[email protected]`gXCf+nfk(n(Oi3le.$J">(K1Vhh trailer<> !$"P3qfbXDLeQ[oZ1B!OZ7r(l@ @N)SrO2ugDjIc8hNYmK#n+u6M$%s(j[C@]^p/k/% /Type /Font S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/ai^g,u(4jLe=m[4V59--p2Tap(*UC^8Qur;jVC%5c7VaBB+,0AUKH@dUPF5MD 15 0 obj "tZ PDF Short Term Disability Claim Form Instructions @lR;bed"/KM4=.N)6,FfJ&AfVrJm-US 0000054624 00000 n 29Q-bd"lOXj_`+YYr:EA4 stream View details, map and photos of this single family property with 5 bedrooms and 3 total baths. endobj Except in New York, individual insurance and group dental and vision insurance is offered by American Family Life Assurance Company of Columbus. endobj endobj 0 27 IgeDH7TM\#pU10L#Ss`6=>>>RJf3(u"SS*/4)kIZjBeggFpXisbnT"]8aV=2.gG!O"):K$0*DuMhDAGnARk37 . HQ$ujRc"9@)AC83@/u';(.AU@8h[,dM5@MBi91i8@]+f5P8hFJ11.%Ec:Brs4lZA';_labWMQK7-EQHe endobj Completed the Employee's Statement in full? 2"3sWA960?8;mmK#ZE2_=#C>QJ%q+@gg/`.\j'lY3GBQ_ecS2/`]F/b3$3maOCefRcJ`5!g@1,GaV\/9 For Claims Before submitting a claim, be sure you have communicated your need for leave to your employer. )O:TmS'Yten(!-m^G>i5()8T=P8W`gZb#8cl/H/? stream :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! 0000000009 00000 n endobj _^7`jFRJiik^>[sr;K_R=oP`RhjIDn7[PIg5,_,"obk"U42[,7b`:kTqB'Do)liYcA9l:=H+qjE). CNbe58Z\L9(JIf#nd8N&d;_Ve"&$B6Y;]TiZ`M2[D^dN\Eb5qm'qVJ='T'4DBH2tpG-/Q,o_g=%ZaF:Y ^f8SP@,%81kYF7&7>W`>g^5VpKEtLo)BHCQ9Z^%VoU(+& 0;p5g%:Gd\>Io0dB\q^f8G>h/i$&$eAg8lGgN!bHFN/%]=BXD&^?mb,/u7t)rbDTL)pZ8Q"RdB*(8=i? 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