1;O*2,G$@I\"rb]Q.4D=II@4)^=0+TVqO'Vmr2I;^-/4+)F;?jKG:nrWIe,-on%\in1XBefUaLD^%V#'74qV#Ctu(;N)%J Please include all dates of treatment and charges incurred due to the accident. 0000055102 00000 n 6 0 obj << /Count 1 /First 18 0 R /Last 18 0 R >> 0000001422 00000 n ]/:~> Request a quote dialog. Life claim forms for the state of Illinois must be obtained by contacting Aflac Worldwide Headquarters at 800.992.3522 to have the appropriate forms sent to you. 0000003079 00000 n /Subtype /Type1 ;PmE,29/@]Q_gjie3>F*fbNG$7H6^5^trSgt@MX18^JE+B$K 1;O*2,G$@I\"rb]Q.4D=II@4)^=0+TVqO'Vmr2I;^-/4+)F;?jKG:nrWIe,-on%\in1XBefUaLD^%V#'74qV#Ctu(;N)%J 0000054923 00000 n eokV:dNhZMi7O%JW^7S3)e7Na-0A!>>14!l. 'L_g'N&-hd[;0t$*n/>649o==0mM=iT3\5)+p[n+X5`?CY@j.i4h`gXCf+nfk(n(Oi3le.$J">(K1Vhh 24 0 obj 0000030858 00000 n 0000000932 00000 n :b_AV)1V(ZcOZDX/m5A*jYG7Ls#=[g?T6ig2h"/>:-ToJWI)s^O endobj nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. 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Execute Aflac Initial Disability Claim Forms To Print within a few minutes following the guidelines below: Choose the template you need in the collection of legal forms. endobj Get more info about Aflac for business owners.. Aflac promised to be here when you need us most and a big part of that promise is making the claims process easy. 2&Tk-bp^c+fLgI$.,d5^! @$)Lh&6Egt'qa=4JCbEhf.D@]'4gOBhAJ\j-2@i1Of6HUn&0Zg!2[-CMUcDL,99I`W(Mo=4ulk";_tepAHfJ;F[K'*>:ebQ]rrd/^N-lJT7#)95uN-MWu5OG qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib /Encoding 4 0 R <>stream 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. >/FRGOB+OB[1iVR22-7Lnt@)K1T_gY[7;kiM;`1C&61:AoC42ST7*!-T+uZ3:t]s'Eh(_u3^02+HBBV< 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY Rf;iu7gGe[$chW^;W6Fl=BqZ%6KIFZ'HNb5)TaYYGG:'$r`) Claims are subject to policy terms and conditions. <> )qT)jZA=U\YiCp>=mtH$[\__]9X3fUD/SEtnbat` "iE5=j8``/gXCMXF Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F ?5QKLuXe>d/Imj No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . 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File a Critical Illness Claim via Fax or Mail. ,-TQAaYC[5-ru"XbG^9qf`7Q_V*TD8eW0!d4tTL2](RU^lH!V+k6L3^9)d)_:\E endobj 0000000686 00000 n [u"0oO\5'j_^6BobJWi[hgme'ak6Kf@+ /BaseFont /Helvetica 0000000446 00000 n 15THsJWlVj?FW\)knqP*Lk! "Jk(XbKsV#$D'i]&;mcIV!r >> <>stream ]/:~> 8*C9[J(Cl:;Gi9qfiditHQ#'L]jC2sPgd`'`W#[3J"LQg0%?W3t_5VRgmCJ5=M#ORRY\sAH6Rq;5+ChV$?jn,^o9SGo>Ha @oGDmsuR- GtHt%Nh;7F1(!K[n[8/1g\PTUNaGT"=n\Bb:62T:Xt#[Q]!mJ,M&0#sD9($J$JR;eXA\0%6Xp-RXgTNJt5f^? 0JTM8HGN-uYUmTOelVf]F4AA)ZISHh>(!HVXe#12]a#X:Z;?uk$a0t'3>1o_N(G1e9TB>Kme4`U:>O6e 7.XdOm?gqE4o-8r9 ;An6Y?l:#h=mlN1\Er Open the aflac initial disability claim form physician's statement and follow the instructions Easily sign the aflac disability claim form with your finger Send filled & signed initial disability claim form aflac or save Rate the aflac disability forms 4.7 Satisfied 292 votes be ready to get more Create this form in 5 minutes or less Get Form %%EOF, %)C64ibd!\^el)-+>j:\a[jWR6/W"V7$&<2ChQ4GQ3m]%-]eU36,7(7&j^8g0t0._o5#)MF+=O0%0JZsOU541%";UhbOU541$qhQCX^U/X4>K3,D$=_4r%W\&S\MZi0BE\KZCLf\GR)(H"TPAbB>9a5R_bAOr9WH[a\MZ.8'b&$<8)CZC!4q/$KA=egJk37Y-1E[86[%\Q8F@Ib#lC'QaPAJ_!-i/?KdVG"X#_=\516`^^\5J,M/.DIa\*YoK("Ilc7:\Z!R!s#oBE\L=Mo^G"0[nG`5V"#mcLGq-fm(][p0CmKXlc98[>OE;Z/7+o2eE!LDjPa!a3Xc:0DZRWnntJY5N;J?0eM/NN[?FDc1*_BD4,fH?NW^RLYY)!s0cFkh7TIbZO^6D,e>Dc*8`HqDdK^f5,@XY;DpFtX]=7B\)[5Tnfu-3$sRuHF:Yh5'IV`6%-m4Y.bOGfjZ)(qBXT;C[`r?0DD5;2)a8.>B\E]#K4+#M?QZ,2jt>l2-a^eJUVSD!$n^V+2KS`Z(&b7f>D\c[,cbDnI4RtYNNY'\j^e:/MTc%[.&Mi>Z89csFkO_me;R=pA8XQ.='6KHrksNkk*r9FX=S4Pgr\U>)LU5Z,0PIFd?h1K=.dmASs68D`.HQBQ8=FLf"fMskfFj8:[Dn597>tbl?nmbEA5SDre>S,3Deg@^FLUSDBA)p%)5RIVgXbP`on^-X@s(>%\g1:1g-Ajr[lATDl@UCM[dLm)1Q1+HU#b])Erj(I@+9m#p4k5]ncg6)T6;E!O;b->F7sSX?aRu-P@hC&7M%b&g/\9Yd'&gar3\#MN%b[$3Y2%,([$$!Sb:YTWCG]j2+aG"2aZ-"`S]Al;)59HFIu;io(nY/H9B@6iFQi3XdcW9Z-V6BgCIF"eCT9P\"M`BQi15C1'7&VWI5c1I.s(>fq'HRp]Cb$Rqk,?C+Y'I/&mA*)/fjc@on>V1EDFR>i9ni(>e6,gV6[.`lEk#T#^0>n4cs+"I$9AbNd6MMHmgP(.+9DS]%Au*>#2LX^T9h_]SOMI20Cj1M&?NqGF(B;h9Cqf?G2iM0gOD]RR;E$7UJHl(Vc3,?YgX1JCUp$h)/n="5=st8J,~> 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 0000001020 00000 n I:V.I`2dr"RI-usXpWjkY@>M8)rABTHrdsdGSrnt>bM>*rdMgSo-0,QN0AdB$2JDlipKX1lo%-6ppko&)?kL6M8p"kK6P^Jj+s;af.%X>Efh47/[PqC. 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We pay claims fast. endstream <> /Subtype /Type1 The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee's Form W-2. 0000054815 00000 n Please provide a certified copy of the deceased person's birth certificate and death certificate. If the cause of death is an injury or accident, include a copy of any related police report and/or newspaper articles. <> 0000000212 00000 n endobj ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d >> <> /XObject << endobj endstream `JaOS[A]]e$%M7QS4Qo!meJ)_CS:m7V7-aS4FZ1PGi:"6tO9;>TbWc_tC3LGp( FXd-mhfj\dS((^`0K6!.q%j)EYH;^Rd.Aa`hf%gahFK:H:&//7pMV3D2qV#r4Oea\q/upjBMGec[O,Y:5n_u^Q$*P(4j$+WU5q!\lQS0:!H;gK 24 0 obj In NY, self-funded plans and absence services are administered by and insurance is offered by American Family Life Assurance Company of NY. endobj V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT 8e==QcdnYk8&(`lkD;,]b;+SbfrO-.*]B,RLFCV[]Pa\Z? YKROsZ>WYNLd_t?65*\J,Z?QVE?JeNB#Lrk^]8>,3&l. 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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). Please complete the Patient section, Boxes 818, as well as the Policyholder/Employee section (excluding Boxes 3138 and 40.) 1 0 obj #DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! 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CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. !o5ERV47$k+S(!Xa"PN!I9]Y4"VHDRe8O[\PP>C\n_[q%@(=l5'/%#n49 (8p@RL@:%uhr=mo1Fg6rg/M;<4* %%EOF, 3T;C!WW4Ki3jpQoiR!f,B'&Z:-,IO-Zq$&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