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. 25 0 obj ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; endobj Administrative services are not insurance and are not considered legal advice. HQ$ujRc"9@)AC83@/u';(.AU@8h[,dM5@MBi91i8@]+f5P8hFJ11.%Ec:Brs4lZA';_labWMQK7-EQHe stream We pay claims fast. N)G#g,5CuOCl3ttm>moVq5\t:irQ`YOX`hI[-7k@LAI*:FcS$CfJQIJO'l@aSJln)/KXYQh;4`]9N;Qj Offer your clients better benefit options with Aflac supplemental insurance policies. View Site Aflac Initial Disability Claim Form Capital Insurance Agency Aflac Initial Disability Claim Form 3. $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K O!61!%9G.V^/"+$60K[1j:%8%V^jr#WgA)E0dmgaHYP)uTIcfaXm(sZ9L'dZ;nA@OpWjJ1,O,)*$t/$< The Attending Physicians statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R 22 0 obj 4DJ',H9cO;3i^o\C+^QV'V04i8_]sBSS$("j]B+50E+CQV5b^gW\=h>i@^d/*Zf(82"&uJ.f5ea9kXJ@ 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; ([eH#15RQ9*WFJq0`khPI=$2a3*8h8?\)&pGHS--no]E3Z-HiTg /2R!i5j&PBRjtAnemGT^T>r)/aH+##c99WL>k&k>=:> 0000000326 00000 n 0000000446 00000 n [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~> "k&*mXEOTDY; m);lB2NZG/rMHahB@? Aflac may include American Family Life Assurance Company of Columbus, American Family Life Assurance Company of New York, Continental American Insurance Company (marketed as Aflac Group), Tier One Insurance Company, and any other affiliated companies (collectively, Aflac), as applicable to the entity from whom you receive insurance services. Universal Life Insurance underwritten by Trustmark Insurance Company. V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib A&!R^maAJpBZW3)>! /Subtype /Type1 endstream Aflac Group Disability Claim Form_2020. 23 0 obj Log in to to your account or Chat with us. 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If this is an Employer Sponsored Term Life Product with your policy number beginning with AFL, please use the forms below. ?/8-TEfAU,j[:b-G[DjC57H"+$-Ag(@hZ 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. endobj /Type /Font ^$F!_M^D.n0(qARn(aE/AgY,iIM9"8CcNDqjSN*8m)"S@.f==Xc1]GcbA-_LZ\:A:pe2tj #DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! 0000000009 00000 n endobj 'L_g'N&-hd[;0t$*n/>649o==0mM=iT3\5)+p[n+X5`?CY@j.i4h`gXCf+nfk(n(Oi3le.$J">(K1Vhh endobj 0000043507 00000 n 0000037564 00000 n Send it in to: PO Box 60676, Worcester, MA 01606, Long Term Care/Home Health Care Benefit Claim Form, Automatic Bank Draft/Electronic Funds Transfer, New York Domestic Violence Notice (For Life Insurance Policyholders). 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File a Critical Illness Claim via Fax or Mail. 0000035380 00000 n .mN(97.aR@?hUC/hmO_H@-r$8(#H,d[mojB7?G" endstream endstream Online Claim Form Aflac https://www.aflac.com/file-a-claim/default.aspx When you use MyAflac filing your claim online is an easy way to get paid fast. <> /BaseFont /ZapfDingbats 34KC`g@bObJ6!O^[4KaLHd&d3Z>1B[8K]!Ma[U/7j$GS6:@5eWk>jl+X?+>PG9h*%gY?g&"\0cQnsu>;4$NAR_h9iPdY^EdXqEH&r&?URsH:@b+fJ3ul5P0*OfoJU+qB&mF'>3T)PgN9! ii0)@:9O(%@H%RrdWERj>N3*\BUO1i]tqg3/1[H/;eAHS(@In[U#O`g'CB(1Z@f9[-o$S-AZ%3&Ipb== 0000003079 00000 n cC5a$qEUFt(E8e->F3f^Yr:J8cr+o+V8SWC.sUDP!9a:YTD`h-6Dlku'HCEL>"u[SakEau DE.V"?h'jom'g4taZ=ggb[Rq9*%"D3_?>DBHcG"%EYhs\A)[02C%,[#:eC])1_\$c?cV\_3\d).P:QmEm*p#YH<04bhGCYr_BRigd-lMFY&qm3!U7+E'.29BdD[1$Xoi)[=&jM/3ntoZ9Yk9SnM:+ Gb"/+>Ak37'`KV3/5eDEgG?/lI4LWa'$ur?W[d*V,h\7l#d?mNJ)Aq(`l\$9r]8mD9i4oAk0uTg\R00ZVV#pc.2Mpm+,=coq-^X\/^2+Ro:*!h7Bm]Cq>98`j38rMql+RHlciXDD:O-.R9_TU-%$KWJ&%EeDSQOMS%tsI0d4a7r9#Ol4'D%E4EK1ujsb..`iHm]`e$)k^"Q^#KkEYKkH,uOP(80*7Z5_G4.i#]hLJ+";I[!$12hJ91\8^[Td+XQ[mPo$8j=s\t4"S,Bl$P(;O%p!s!Ku[I>D!+-:qp&44s&b-79$g5X8KRm;i)J?CM@uJaJZ3^-Eoca:2/860Oi73ej_sH/OffcPpc'hdKu0-^ag$H2rn97h7g81oHMqEm$5MWrPmpU?7DD#UMab$5%_[b_8>?O8;6s">eu$N?n%Q3o!,Df>u?kJq2$m(FDMD"##D'#q#CTD?)CYs'$I(M@4F-U::15Q%CU1Ro3Znq41#6.+o_=5ii9S"&"'.+G;+5G!,8*WI.NQditfNp9BF#01UA\LPkPqV*j[??CiX;jR$FZSrI"OH.>ON%;Ij+oGrA6_YW^6Z:!B#$R,Fga=;d&7Zk($aUr))R"L3#^biuj386G.RNZLhK?kf]F0C&fq"inaEpKV4E2>X7d8DIY6;Od8q0GVqWGT#j0+5q;T=*+akW/tBoYQZ.c%]"Z=@H@m>d&O9S+u."e1@+;2U6W%)#".951Q^Z6=7m[06H>UTb9BB]]glBFmRjNR5\N62KH_K>KYfo+E%Frhsu6TYdn\:>Kr^8ZIITr1#;ZZF>&LhZH?p%;L"7B&5Gaa=8<>M&:elHR^d4hNj[S!V$=Me)\^I&hPmkGd0/QWmOLQegbEX,A28`%VVVgJ`0\b(?LY4aeE3T!+!4FA>+S26ZT+Ed!jr*!@8f9GrZ2q4^e]="@ec#*$7\..9,ltUZ9q^eON_e:e%(!Kr*o./j1.p&=]K^rjJBVaGFUOgr45.]M%0dIX02r,f!NFbT5k42%b2k\MC#%\(4sUMj[6p`^1<>g'nP4]>\lG^]-Q)'CTnjM'o[`6*$PjK+BrkMHD4-^)R-/Z(SRB6#G_eY*]&-Q-,K,\)d@;keV2q;l.W;?kHXKR"tW"h:3>=R$Wt$KTEFmQ7r^^[N'B^a!Sb[u7NG^1HW6hGC_j$97psFCSS((]FUF>k4CG%[Y^c^5&QoktoiXau4dM^'1J.I6gA.h-?X<8t,sDhU@I7WWUL(U)&bG*FWGeFY`f'W_-n)(^0F7WjosHEeYC,WDPPDqbj?f1Y)IC"7k_H(rZu^!\6VZ"Fac7jM>lmos.nt"CGREi"b7BHP35;PQtiF"Y1Pb/A3fP"%2/kf7(!A:",b6i%gA>LWNPaR"+2'4e"QPBY'qVb"KM^pc_eAmpUIh#*-Ln\RsSU2i:)Ldl[:U?4_b#H/MgO*cPThRX*eUeTc%[*`L%TM=2\3\BN3Z*tTlg]Y>_&0]U+n.bDg0DdPK*X)BePkCk\ms&+Dkos;Ka3=K/fXjT.?,t!-IbTfJUp=jf:8T_2&s'+(/.h=j/O9fh(^YS'Co7!4#IZV(+Pfu#A/KIARp[>2\:3q(PedG.mRZ.4B:e1fDag*F#o4Ersmuq7OH`g&f1$LYcjY7O,U0QT2BYHr_p^&[03aUoihTl0LFDN.ikW)D+ZecfR[[u4*@bg/rWb0P936uUo^J$CLiNn/3c].L=V.c). mQYc=\E9,ERP]c]=8bqqqY%CP/fB'k8=no-Ws101`o*'eZs]oap*qMF 0000054442 00000 n C)U\u?j:;&T7I/iGm[n\T;_)`gEYqdm*YLN@N-_eg4^hU\]H7Co2_+ugag&:Fd?U>McjOT-(PdfS7Ma7 endobj <> )_uYFAPMnh@@qLR(!tj0,JgDV:^2aU1j,Q1G5%+A&.^pn]C"PJA:oAllMYj0psPAVZ_E,8iGS^\I&;A'/E"CXIR`WpK_.^,?uB7C2c/q!Ft;r%bq\)j#XX/c~> %+7qEQTFU"'i_\(/=gq+JNS@%Y-$pZB>:Y4*(rCZfQj@Kgqq^GWEccM#up\R$:Ie]Cf@mqFQ&(pWqBMr >> For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York. 25 0 obj h/#o:*lSpdqlZg*XqFsNY5T/YFk%>_'?0&0X0BaP:*/_(BP1Z\9IQQ3"3LWkO02ijH;rAcRPahK(DRaJ ]_h\LUlKWpDX[03gS"tG,UJ0*mL9UkEk%7OIX,#u6?P_/\,44Z>m2`cW$i)b*qRV/6raU^h/W^<6?6JC;$U>eK_"kZBZcu]&\dTh"\!Q%B8?1?Rk8,^p^Wn[RC5_%c^'XQF+or lPl9tY-IJ%_lFQbBP+,UB6!AO?&Q*kaBs. :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! endobj 0 27 ([eH#15RQ9*WFJq0`khPI=$2a3*8h8?\)&pGHS--no]E3Z-HiTg *PolicyNumber: / / - --Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementof 'X-2uc/>cM8\5p/T44i`BgV5"LY/5Yg% #uY.o`Vd[Bd.YT[///3UJY[r*;n,NhjZnQjdJ7=`r$)Ri)3:i(@X2#3?N.HcWa:.*$kP? /Subtype /Type1 eokV:dNhZMi7O%JW^7S3)e7Na-0A!>>14!l. 8*C9[J(Cl:;Gi9qfiditHQ#'L]jC2sPgd`'`W#[3J"LQg0%?W3t_5VRgmCJ5=M#ORRY\sAH6Rq;5+ChV$?jn,^o9SGo>Ha S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/ai^g,u(4jLe=m[4V59--p2Tap(*UC^8Qur;jVC%5c7VaBB+,0AUKH@dUPF5MD No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . 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'L_g'N&-hd[;0t$*n/>649o==0mM=iT3\5)+p[n+X5`?CY@j.i4h`gXCf+nfk(n(Oi3le.$J">(K1Vhh 14 0 obj 'oHV-TGH;:1osTnm1H fU$\OG4-O2)(5'UZNJ?f73M.5b:i7_h](4!r@! 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Claimsmaybefaxedto1-877-44-AFLAC(1-877-442-3522) NY-S00224NY Page2of3 02/14 *LastName Suffix *FirstName MI *DateofBirth(mm/dd/yy) *Employee'sName(LastName,Suffix,FirstName,MI) *Employer'sName/Account# *Employer'sPhoneNumber INITIALDISABILITYCLAIMFORM-EMPLOYER'SSTATEMENT EMPLOYER'SSIGNATURE EMPLOYER'SPRINTEDNAME TITLE DIRECTPHONENUMBER DATE 21 0 obj [u"0oO\5'j_^6BobJWi[hgme'ak6Kf@+ 13 0 obj 6 0 obj stream p!WHg/S/1>qh13::;;66rN. "iE5=j8``/gXCMXF Form # 1015 Disability Claim Filing Instructions Have you 1. 18 0 obj 24 0 obj "Jk(XbKsV#$D'i]&;mcIV!r *?ZgaJ72F%->d4aYIUb3reE0'[sM)3JY+[(7="R\fM6;Q ::bl''..9BC;a\$BlT\:t-X,fsW*QN`2e(KL I)%]TcA`mWhX>Fb(1P"hjhfpCIF@eR>[8Uk8jb3JJCK>D0o*mhlN*%U(90mDYL0F##rb&>4GjbSZj8#' <> eiE#q%9eO%886=-()4_+S4PR>Y.OpD>thDms)r(iY76&nF\4eSBh"@D8Ckg?OT/fVbq-a!hKg2P8WFKC*e*%O1YLY&R&=h#U$ <> /XObject << 0 27 Use the Cross or Check marks in the top toolbar to select your answers in the list boxes. TiH!-bXfof5[n@&[kS/JgZ:HFlTDHBWer?faRZL For disability claims, we will need information from you, from your employer, and from your attending physician. American Family Life Assurance Company of New York | Albany, NY /Subtype /Type1 Please complete the Patient section, Boxes 818, as well as the Policyholder/Employee section (excluding Boxes 3138 and 40.) qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib endstream endobj h0cQ^!FY^@5YZ9`C((MZ9iSNHc>@i(/A6Ang=Q>29[%f,N\.ZX(j>Mqs0Q)QK[VqWr`O1c][Ae6 $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR /Encoding 4 0 R <> stream Request a quote dialog. endstream %PDF Font (F27) ]n9eB$>Q3/Zh8hTCilrgR.+jiDh,K#srd-U9acuKPd@,V`j5BhbA8I "iE5=j8``/gXCMXF Products may not be available in all states and may vary depending on state law. 0000054815 00000 n If the cause of death is an injury or accident, include a copy of any related police report and/or newspaper articles. endobj 29Q-bd"lOXj_`+YYr:EA4 endstream Direct to Consumer Business is underwritten by Tier One Insurance Company, doing business as Tier One Life Insurance Company in California (Tier One NAIC 92908). endobj <> 11 0 obj 24 0 obj xref <> k0Q'9K%4rkrrN3]cu8p8';m8q-eHY2Sa?q0DqdO_]i_5()gWNP#-%H8k&XV=Id,j>)pb@S-4-ot]OZm4 )O:TmS'Yten(!-m^G>i5()8T=P8W`gZb#8cl/H/? c5lMh,QXUsVpDOgY[E488MHV?GK9DUk^qXiSo6?d"#T=f:;YTi0SU1_S\M2I.26bpPB\Xsl"fN>oQoH- /Type /Encoding Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K ?5QKLuXe>d/Imj (0h]6sfh&ctrb/lSmDh5-O.iae,IL6uU^p;6R$coc.i2=RBLFrO3lTLkd^8 0000001422 00000 n endobj !o5ERV47$k+S(!Xa"PN!I9]Y4"VHDRe8O[\PP>C\n_[q%@(=l5'/%#n49 %PDF Font (F7) 19 0 obj /BaseFont /Helvetica-BoldOblique <> /XObject << Aflac promised to be here when you need us most - and a big part of that promise is making the claims process easy. Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r ]_h\LUlKWpDX[03gS"tG,UJ0*mL9UkEk%7OIX,#u6?P_/\,44Z>m2`cW$i)b*qRV/6raU^h/W^<6?6JC;$U>eK_"kZBZcu]&\dTh"\!Q%B8?1?Rk8,^p^Wn[RC5_%c^'XQF+or TLFC\4aS)n5C^j*@4%"P0VVa9rj(. "Jk(XbKsV#$D'i]&;mcIV!r Group policies are offered by Continental American Insurance Company (CAIC). 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