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Please choose "Individual" or "Business.". FuFfnc;)7cKg['Zqu$@#^.Lm;P)OIh\R^_`-@):D`Br-$pdOd.\.5Vk2j_jL6C'[%-[(4
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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"&$B6Y;]TiZ`M2[D^dN\Eb5qm'qVJ='T'4DBH2tpG-/Q,o_g=%ZaF:Y
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Please provide a certified copy of the deceased person's birth certificate and death certificate. #uY.o`Vd[Bd.YT[///3UJY[r*;n,NhjZnQjdJ7=`r$)Ri)3:i(@X2#3?N.HcWa:.*$kP? endstream *PolicyNumber: / / - --Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementof 'oHV-TGH;:1osTnm1H
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endstream Aflac lets you provide your employees with outstanding benefits without costing you a penny. "iE5=j8``/gXCMXF
endobj endstream endobj 0 27 0000035380 00000 n endobj For step-by-step tutorials on filing an online claim, please see our claims checklists. "-e/G/_P"pf.N+3cau8Z.,JJ6Rk;MRVJDs
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endobj 22 0 obj 0000000932 00000 n . Your employer is responsible for providing the information in Part B, and your attending physician is responsible for providing the information in Part C. In addition, please read and then sign the Authorization for Disclosure of Health Information (HIPAA form) included in Part A, as well as the separate Authorization for Disclosure of Health Information (HIPAA form). "iE5=j8``/gXCMXF
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2@Aq[=+(TD3oRc#`>K/0ZNjU%/:30? Simply select "File Online" below and follow the instructions. )lM~> InitialDisabilityChecklist Isdisabilityduetoasickness? A(lCW]h%VdMt:8Y)JTJc(@p\,K2F73Vt)lr]_VGs^b4MoT7ZmT:ZlP&6C?-PWabHK;JrCnJnrcc
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0000037564 00000 n No Yes Isdisabilityduetoaninjury? m-*&@,H9g(2[5#o!G;R4U9IEG=[4#Wq9g71
16 0 obj endobj 0000054923 00000 n 0000054519 00000 n For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York. << <> /XObject << 3. >> 0000055102 00000 n 2&Tk-bp^c+fLgI$.,d5^! 0000000446 00000 n <>stream ]_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
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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[
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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
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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.