[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~> !o5ERV47$k+S(!Xa"PN!I9]Y4"VHDRe8O[\PP>C\n_[q%@(=l5'/%#n49 o5BD$*Z2jom$PZ&;ZZZSrkbZVqI! endobj 21 0 obj "DFX!Fen1$B29'W4#sWKq Please choose "Individual" or "Business.". FuFfnc;)7cKg['Zqu$@#^.Lm;P)OIh\R^_`-@):D`Br-$pdOd.\.5Vk2j_jL6C'[%-[(4 6,k1;gaBDk.XY%J:F9As.#C&J>pqd^X_`2(g"7EVNm@*ELI1%cI CAIC is not licensed to solicit business in New York, Guam, Puerto Rico or the Virgin Islands. 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. *Jn&hZmHE?Eu$9%^_jrU\Fh>uH`k,8rK No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . Group policies are offered by Continental American Insurance Company (CAIC). cC5a$qEUFt(E8e->F3f^Yr:J8cr+o+V8SWC.sUDP!9a:YTD`h-6Dlku'HCEL>"u[SakEau 20 0 obj endstream All forms are printable and downloadable. View Site Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf CNbe58Z\L9(JIf#nd8N&d;_Ve"&$B6Y;]TiZ`M2[D^dN\Eb5qm'qVJ='T'4DBH2tpG-/Q,o_g=%ZaF:Y <>stream /Subtype /Type1 "kt65Ko1TNq1+;X4?fH1W0SbI2D-F(6cs2(!E?1oM!HZ/`bJ.Cb4@4gWrBVNX,G01o;?NA0^%)?aS>EJ endstream 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H? 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"-e/G/_P"pf.N+3cau8Z.,JJ6Rk;MRVJDs endobj 3TjKSEQ8:S+XUe3iJa"79`?s5c,-YU]aQt>=/Q\K4ePWk8tUHMNos%)gp)1M'YH]uh'HQ!l(m'P9e66@:#UA1$A@flpm endobj 22 0 obj 0000000932 00000 n . Your employer is responsible for providing the information in Part B, and your attending physician is responsible for providing the information in Part C. 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). "iE5=j8``/gXCMXF <>stream Follow the step-by-step instructions below to eSign your aflac wellness claim forms: Select the document you want to sign and click Upload. 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Simply select "File Online" below and follow the instructions. )lM~> InitialDisabilityChecklist Isdisabilityduetoasickness? A(lCW]h%VdMt:8Y)JTJc(@p\,K2F73Vt)lr]_VGs^b4MoT7ZmT:ZlP&6C?-PWabHK;JrCnJnrcc <> 8,Y5:-bZ-;Z%c':c]*),@W=_c. "tZ k%Q-/:EP^K/u*2f#eWVR['(Z7F!QM(!m?U.3>lak?8[tRmj?FN/_d2^MMq-[cT:Gp[D^&q<0d#8`Q3)) InitialDisabilityChecklist Isdisabilityduetoasickness? N8EYJ/rdd(..BX8/1[!lhITlJFmO/CsZ%j/>QaJ13;:-PF0g ?NAW _0kQ98&!$i3)qj(aoD$GE4ichZTh10fLUX?o`T)Tp(DKE$D,A)o)nXcqGjE4Kf$SW?d(38p]9$)m%!a_ <> <> 23 0 obj << << /Count 1 /First 18 0 R /Last 18 0 R >> TJ(bq:!Ce_pc=2B1P"%7$HG=ui[FCuL+*6":'=rM2is:GPB$q%ZHU@,+FueOi0ob+.\6Ek;q7r%XbW$S 0000055045 00000 n X3^f``c_A)\*/"78h!p%/*in2gI^?CblC`0:Dk,=U@Ip$RaFkC-A%5t[ObE/d?Sc8c!X5%k0qkA1$A(f 25 0 obj -8KU)@AZCLegJ8ge%BBp0g(_Y&;BmiFJfS%>@Gu7. 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"k&*mXEOTDY; /Filter [/ASCII85Decode /FlateDecode] IgeDH7TM\#pU10L#Ss`6=>>>RJf3(u"SS*/4)kIZjBeggFpXisbnT"]8aV=2.gG!O"):K$0*DuMhDAGnARk37 8e==QcdnYk8&(`lkD;,]b;+SbfrO-.*]B,RLFCV[]Pa\Z? Consider filing online for faster claims payment! Please provide a date and complete description of your accident. Distribute immediately to the recipient. 0000000446 00000 n e(d`r+1(IK_Z9J8FZEKhh]p"mOP2o\*_i:B,oR:q;pr&)1JfnGrF_2WN1&RdVP7b@X=`\9QI&,k/0N4e 0000035380 00000 n Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). a8BPfZ&sW[D\qX`_,022h,5IoVd[ startxref endobj 0000054923 00000 n (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!AicdVn^"gp(^-oKqo#i"gBOsIn1fK.\PJgLt&^imq7BSJ..gu`g3TNp]lZQ:Q+PSQZ=7bSOhN`;B#7;s#7r)aO+XB?-BFdCkA(+.VnQp*5O$?iSK/`O.QJ'S)/aPDmhO:I1AIuZ^Ves%d@6'UQ5gRhf3BF`kXpaej\IRil\Y_Tp',^\5b3DiW.2X/9G,ZBZNQ1%0jnNTP=-/t4]pG5O*!$Hj%$(Vi!33gU7QS]rt"S4I%1~> rU4bL8-39(G ([eH#15RQ9*WFJq0`khPI=$2a3*8h8?\)&pGHS--no]E3Z-HiTg c)$el$_7T'R>`H4d?VZZ.6:FXa^5[8hKt_jJ5`+n^Hma14HF`L'+tk,U=9slnfp8]Z?2MS[;()=`R 0000000009 00000 n _^7`jFRJiik^>[sr;K_R=oP`RhjIDn7[PIg5,_,"obk"U42[,7b`:kTqB'Do)liYcA9l:=H+qjE). 16 0 obj << /Count 1 /First 18 0 R /Last 18 0 R >> 3 0 obj ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; 0000000563 00000 n ([eH#15RQ9*WFJq0`khPI=$2a3*8h8?\)&pGHS--no]E3Z-HiTg T9khijaBNZR9C,%t"7Fg@HCRo`)?gN`jH7$+&;F&1h$f-gZ@qpFS8g[qONg*?3muhSPi%q01m@ EMnIpA`\`j9p%8Jb%g?3bB@@W^$A.t>R)@AV[$Gr+1aic5NY;`=A9#XB->:2MDO^@t[9!^9`hM)b9[&5Hfki>iJ2*idRMc*I1K7B)P.Ht.`'k-.R`,bZ1``cJ !o5ERV47$k+S(!Xa"PN!I9]Y4"VHDRe8O[\PP>C\n_[q%@(=l5'/%#n49 This form may be used on all product claims except Group Term Life, Group Whole Life and AD&D claims. 23 0 obj 18 0 obj [W_J1(2pZ1HC$V;V*/7\3N-"m8ACA6(\G4_j7tLZo4PDu:9kltQ:qtrOFJei`3u25)_cfnQ2M,M>*2Sb 2. Submit all the requested fields (these are yellowish). HQ$ujRc"9@)AC83@/u';(.AU@8h[,dM5@MBi91i8@]+f5P8hFJ11.%Ec:Brs4lZA';_labWMQK7-EQHe 26 0 obj 0000049255 00000 n endobj 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~> 0000040092 00000 n endobj 1g!5D-LsIWRBY-X(8X2r&@O_`0*:d@O.-Wcm!Ja'h?grDR1Nq&[A-=2b! AkJD?1M>up>BcsX+I=_#LC$k%qGLcEUfd4i%!i& 0000001020 00000 n >> If you disagree with a claims decision, you may submit an appeal citing supporting policy provisions. !$"P3qfbXDLeQ[oZ1B!OZ7r(l@ 0000003079 00000 n endobj The Disability Claim Form (Aflac Insurance) form is 8 pages long and contains: Use our library of forms to quickly fill and sign your Aflac Insurance forms online. :^_n)prV#UtcF7_C)h7^7 #DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! Select the Get form button to open the document and move to editing.