/CreationDate (1/24/2023 00:45:44) )F9)MP$gjIIV>!H Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the Pre-Existing Investigation Statement. 55184 For groups sitused in California, group coverage is underwritten by Continental American Life Insurance Company. ["`,abhS3LE"C=T6]&k%"Zl4BdN^JG3F!Y*CQe"Xqj- endstream A&!R^maAJpBZW3)>! /I1 14 0 R /P0 15 0 R /P1 16 0 R /P2 17 0 R *-ogCe2UsEgf\'ds_/jiZfh5I(c[]]fP=H[DUhhQ4'/;X2hk?KsbO!`rDQ2eS&bFI1P0&@J-^!k9`KO(igH\q^TX%?G:9) . TiH!-bXfof5[n@&[kS/JgZ:HFlTDHBWer?faRZL Enter all required information in the necessary fillable fields. rT)4FF1EPoVMN14>L,`\V:)bIb1npmugX^4,7NbhZ&&T,/8(>f=lM4?OnHSHRdi We built our online claims process to save you time and to help give you peace of mind. 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If your disability is being extended, you will need to complete the listed Supplemental Claim form. 15 0 obj /Encoding 4 0 R endobj Create an account using your email or sign in via Google or Facebook. <> <> Submit or View Your Claim a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. 3TjKSEQ8:S+XUe3iJa"79`?s5c,-YU]aQt>=/Q\K4ePWk8tUHMNos%)gp)1M'YH]uh'HQ!l(m'P9e66@:#UA1$A@flpm mhQCujn[DM`k5Vu9TL8/lY,n@)69`YnLctGSmP1C9g-Y\7nk0=`m#b/(aquK(k!OU2OhA)L%au^_^KfM &>7[>d7(qqN/lSW8,9((\,+tAibO:g1>Tl'K;D\HUqeC^#X0pPUXu3oeqYppd\O0nI(-OoF3]X=)@;7_ *PolicyNumber: / / - --PatientInformation: *LastName Suffix *FirstName MI *DateofBirth(mm/dd/yy . @N)SrO2ugDjIc8hNYmK#n+u6M$%s(j[C@]^p/k/% 0000000212 00000 n *-ogCe2UsEgf\'ds_/jiZfh5I(c[]]fP=H[DUhhQ4'/;X2hk?KsbO!`rDQ2eS&bFI1P0&@J-^!k9`KO(igH\q^TX%?G:9) Aflac | Login Please log in New user? I:V.I`2dr"RI-usXpWjkY@>M8)rABTHrdsdGSrnt>bM>*rdMgSo-0,QN0AdB$2JDlipKX1lo%-6ppko&)?kL6M8p"kK6P^Jj+s;af.%X>Efh47/[PqC. 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Distribute immediately to the recipient. endobj ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d xref [u"0oO\5'j_^6BobJWi[hgme'ak6Kf@+ XL9IY_,^5e)u%m(QSW8`,Ms+JJ"IKSqK)]ClhR1"S67]3AnXNZbU5t!S#5jg;<=EaA8%\YmR9]u3\kc^ :b_AV)1V(ZcOZDX/m5A*jYG7Ls#=[g?T6ig2h"/>:-ToJWI)s^O 5]mS)I&\m'[NsCj]sr@0El\`]Uq+.S367pgfd2I2(=P['dU+EV"7XqK'c7K%if?fQ]VP 2#Uk88j6F;!LPJCYg?_VnT>DO7>((M$tI28>B]"L9/3#3R1],d$6!$JJRKV2m(tG_Q]-T()Va>`2T]>l;eK>s(U,g-lu^? 55184 MLS# 1864947. TNMF9_Vr2,SFTeXfUSJa)jt-'"mb39a6fe"7:L*nQB6WHc=tGuKXhdlF@JojFLBR3CIdNL;Gs\omg&R3 0000030858 00000 n ;An6Y?l:#h=mlN1\Er <> IulVik4tYO+5Y]5dC6+if#]pW>?S#%PB"2$kEPR@U_!W)J++r5@@21spCE@V_m\2SM=jcqaH.-P9&U%f 0000043584 00000 n Please fully complete the claim form for the Wellness Benefit. <>stream Select the Get form button to open the document and move to editing. nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. 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Aflac Sickness Claim Form Physician's Statement If this is a Disability Product with your policy number beginning with AFL, please use the form below. @lR;bed"/KM4=.N)6,FfJ&AfVrJm-US 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 ;dps@dXdX$3sN65dLrqK;34,XZ>#G6k1;= << 0000000814 00000 n 0000030858 00000 n 8;U4*8AZ=@b:l^dJ*L_0.&7i0E^jm_'-W 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, File a Hospital Indemnity via Fax or Mail, NY - Accelerated Death Benefit Claim Form, NY - Waiver of Premium Claim Form-Initial, NY - Waiver of Premium Claim Form-Permanent, NY - Convalescent Care Benefit Claim Form. 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How To Recover Lost Saved Game Data On Ps5, Samantha Berg Coma, Articles A