Do not include receipts, statements or other documentation. Your continued use of the web site shall constitute acknowledgement and agreement with such updated terms. Continental american insurance company caic, a proud member of the aflac family of insurers, is a whollyowned subsidiary of aflac incorporated and underwrites group coverage. Please complete all sections of the form, sign, date, and mail form to the address shown below. If you are interested in filing your claim online, register using smartclaim. Your aflac new york policy provides one wellness benefit per covered person, per calendar year, and this. Wellness and health screening claim form failure to. You understand and agree that aflac may update these terms from time to time by posting revised terms on this page. Accident wellness benefit claim form failure to complete all sections may result in a delay in processing this claim. Do not attach receipts, statements or other documentation to this form. Aflac accident hospital indemnity wellness benefit claim form. Claiming insurance is a much descriptive task, where you have to describe many details about your disease, disability, illness or accident etc. Aflac printable claim forms esign pdf with electronic.
Accident wellness benefit claim form instructions please use black or blue ink only and print legibly when completing this form in its entirety. Was this injury caused by an incident that occurred while performing the duties of hisher employment. Accident wellness benefit claim form instructions please use. If you are interested in filing your claim online or uploading documentation on an existing claim, register. Claims department worldwide headquarters 1932 wynnton road. Be sure to sign your claim form at the bottom of page 1. Claims department worldwide headquarters 1932 wynnton road columbus, ga 31999 for information or help filing. Thank you for trusting aflac with your accidental injury needs. Was this a motor vehicle accident in which the patient was the driver. Keep a copy of the supporting documentation and this completed form for your records. Continental american insurance company caic, a proud member of the aflac family of insurers, is a whollyowned subsidiary of aflac incorporated and. To prevent delays, please provide documentation from your healthcare provider to support this claim. Life claim forms for the state of illinois must be obtained by contacting aflac worldwide headquarters at 800. The advanced tools of the editor will direct you through the editable pdf template.
If disability, is later, determined to be for a longer term, there will be follow up forms required at that time. The way to complete the online aflac accident hospital indemnity wellness benefit claim form on the internet. Incomplete forms cannot be processed and will be returned. Please use black or blue ink only and print legibly when completing this form in its entirety. Aflac is a voluntary benefit policy that is paid entirely by the employee. Download aflac accident wellness benefit claim form pdf. Aflac accident hospital indemnity wellness benefit claim. The claim cannot be processed until all necessary information is provided.
S00198ca failure to complete this form in its entirety may result in a delay in processing this claim. Aflac is not licensed to solicit business in new york, guam, puerto rico, or the virgin islands. The advanced tools of the editor will direct you through the editable pdf. For information or help filing your claim, please call tollfree 180099 aflac 18009923522 or visit our web site at aflac. Claims department worldwide headquarters 1932 wynnton road columbus, ga 31999 for information or help filing your claim, please call tollfree 180099aflac 18009923522 or visit our web site at. To prevent delays, please provide documentation from your. Bills for treatment of this accident along with any accident reports. Mark only wellness exam boxes for tests that you had. When you use aflac smartclaim to submit accident, cancer, hospitalization or illness claims online youll get paid fast. Please submit the pathology report used in the diagnosis of a malignant cancer, the claimants birth certificate, and any itemized medical bills with the diagnosis and. To help provide relief for puerto rico policyholders affected by earthquakes, aflac will defer premium payments coming due for. In order for your claim to be expedited, we need all the requested information at time of claim. Failure to complete this form in its entirety may result in a delay in processing this claim. Aflac does not replace your medical insurance, but is designed to complement your current.
For information or help filing your claim, please call tollfree 180099aflac 18009923522 or visit our web site at tollfree fax number 187744aflac 18774423522 any person who. Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementof. Each additional treatment date should be on a separate claim form. American family life assurance company of columbus aflac attention. Please complete all sections, sign and date, then mail or fax this form with the following information to the contact information at top right. Some of the tests listed may not be covered under the wellness benefit of your policy. Failure to complete all sections may result in a delay in processing this claim. Wellness and health screening claim form failure to complete. Accidenthospital indemnity wellness benefit claim form. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. This form is what you would use in the event of injury from an accident or it may be used if you have benefits that cover wellness procedures such as. Cancer claim form physicians statement american family life assurance company of columbus aflac attention.
S2029ca american family life assurance company of columbus aflac. To help provide relief for puerto rico policyholders affected by earthquakes, aflac will defer premium payments coming due for affected policyholders, starting december 28, 2019, and ending march 9, 2020. Aflac short term disability claim form initial disability. This form is used to file a claim for short term disability. Failure to follow these instructions will delay the processing of your claim. Accident wellness benefit claim form do not write on form except as instructed. American family life assurance company of new york aflac new york. Fill out, securely sign, print or email your aflac accident claim form cooper farms instantly with signnow. American family life assurance company of columbus aflac worldwide headquarters 1932 wynnton road columbus, georgia 31999 1. Sign, date, and mail or fax the completed form to the addressnumber shown below. Claiming insurance is a much descriptive task, where you have to describe many details about your. If you are interested in filing your claim online or uploading.
The facts say you need the protection of the aflac accident advantage insurance policy. Keep a copy of the supporting documentation and this. Accidental injury claim form failure to complete this form in its entirety may result in a delay in processing this claim. Aflac printable claim forms fill out and sign printable pdf. Start a free trial now to save yourself time and money.
American family life assurance company of columbus aflac attn. Download aflac short term disability claim form, also known as aflac initial disability claim form. Continental american insurance company caic, a proud member of the aflac family of insurers, is a. When you use aflac smartclaim to submit accident, cancer, hospitalization or illness claims online by 3 p. Download the aflac short term disability claim form pdf. Policyholder signature printed name date date of physicians visit. Pdf accidenthospital indemnity wellness benefit claim form. For information or help filing your claim, please call tollfree 180099aflac 18009923522 or visit. Pdf accident wellness benefit claim form aflac group insurance.
We care about aflacs policyholders affected by the recent severe weather. Hence, the form is also a lengthy one, and contains many fields to accumulate all necessary details. My revocation must be submitted in writing to aflac, attn. The most secure digital platform to get legally binding. Thank you for trusting aflac with your hospital indemnity needs. Accident claim form failure to complete all sections may result in a delay in processing this claim. Pdf accidenthospital indemnity wellness benefit claim. Claimantsignature familyrelationship,ifnotpolicyholder date page1of3 0708 cancer policynumber shorttermdisabilitysickness disabilityrider policynumber. Benefits are payable to you unless we receive written authorization from your provider to assign benefits to them or from you to pay your benefits elsewhere. If disability, is later, determined to be for a longer. And since we can process your claim quickly, aflac helps give you the peace of mind knowing you can spend more time recovering and less time worrying about bills. This form is what you would use in the event of injury from an accident or it may be used if you have benefits that cover wellness procedures such as mammograms or pap smears. Complete policyholderpatient information and sign your claim form.
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