Please provide all information requested on the Insured's Statement portion of the claim form. Coverage may not be available in all states. /Type /Encoding /Subtype /Type1 %PDF-1.3 endobj
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7 0 obj File an Accident Claim via Fax or Mail.
%PDF Font (F27) If your injury occurred on the job, a first report of injury filed with your employer must be attached to the completed claim form.If you were first treated in an emergency room, a copy of the hospital discharge papers is required to verify the first date of treatment, diagnosis, and procedure.Please include all dates of treatment and charges incurred due to the accident.Please date and sign all required forms where indicated.For critical illness claims, we need information from you and your attending physician. /Encoding 4 0 R
File a Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider ClaimFile a Universal Life Insurance Claim underwritten by Trustmark Insurance Company ClaimFile a Universal Life Insurance Claim underwritten by Trustmark Insurance Company Claims may be eligible for One Day Pay processing if submitted online through Aflac SmartClaim®, including all required documentation, by 3 p.m.
8:00 AM - 8:00 PM EST You can provide this information in the designated space on the claim form.If the accident resulted from the use of a motor vehicle(s), a copy of the police or accident report is required. Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form).
AFLAC - Accident or Injury Claim Form; AFLAC - Accident Wellness Form; AFLAC - Cancer Claim Form; AFLAC - Cancer Wellness Form; AFLAC - Continuing Disability Claim Form; AFLAC - Hospital Indemnity Claim Form /BaseFont /Helvetica-Oblique Refer to the plans for complete details, limitations and exclusions. >> Documentation requirements vary by type of claim; please review requirements for your claim(s) carefully.
>> /Type /Font %PDF-1.6 %���� S00198CA Failure to complete this form in its entirety may result in a delay in processing this claim. Select a date and time you'd like to beBy hitting submit, I agree to receive autodialed calls, to include scheduling reminders, and texts from Aflac, an independent contractor Aflac associate, and an Aflac Partner, such as Sutherland Global Services or Clear Link Insurance Agency, LLC working at Aflac’s request, at the number provided. 11 0 obj
Our customer service representatives are here to assist you Monday through Friday 8 a.m. until 8 p.m. Eastern time. Failure to complete all sections may result in a delay in processing this claim. © 2020 000 >>
If the cause of death is an injury or accident, include a copy of any related police report and/or newspaper articles.Please date and sign all required forms where indicated.To file a claim, simply select the appropriate claim form for your specific product and mail or fax it to us at the address on the form.3. Available for PC, iOS and Android. endobj
Claims may be eligible for One Day Pay processing if submitted online through Aflac SmartClaim®, including all required documentation, by 3 p.m. << American Family Life Assurance Company of Columbus (Aflac) ATTN: Claims … >>
The plans have limitations and exclusions that may affect benefits payable.
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endobj Please review your policy for specific benefits covered under your plan.
>> Individual coverage is underwritten by American Family Life Assurance Company of Columbus. ¢£™…�” Individuals & Families [email protected] . ACCIDENT CLAIM FORM. Please provide all the information requested in Part A of the initial claim form. © 2020 000 %PDF Font (F56) Title: New Claim Form PDFs for WEB - S00224 Author: Registered to: AFLAC Created Date: 4/10/2014 14:39:54 12 0 obj endobj
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