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Accident Wellness Benefit Claim Form


Accident Wellness Benefit Claim Form
Do not include receipts, statements or other doc umentation with this form.
Your Aflac policy provides one W ellness Benefit per policy year. Please note that these benefits are not payable for
treatment within the first 12 months of the policy’s effective date. To receive your W ellness Benefit, complete the form by
following the instructions provided. Please keep a copy of this completed form for your records. Claims for all other benefits
co ve red under your p olicy m ust be filed separately using t he appro priate cla im form.
If your Aflac policy also pro vides a Mammogra m Benefit, please mark the a ppropriate box a nd indicate the da te the
ma mmogram was performed. Please check your policy fo r spe cific benefits cove re d under yo ur po licy .
If your Aflac policy also provides a Pap Smear Benefit, please mark the appropriate box and indicate the date the pap smear
was performed. Ple ase check y our policy for specific be nefits covere d under yo ur policy.
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Please read all instructions.
Failure to follow these instructions will delay the processing of your claim.
ACCIDENT WELLNESS BENEFIT CLAIM FORM
Do not write on form except as inst ructed.
Incomplete forms cannot be processed and will be returned.
Please do not fax this completed form to Aflac.
Mark only w ellness exam box(es) for test(s) that you had performed.
Z06197AD FL
American Family Life Assurance Company of Columbus (Aflac)
Attn: Claims Department 1932 Wynnton Road Columbus, GA 31999-7251
1-800-99-AFLAC (1-800-992-3522) aflac.com 1-800-SI-AFLAC (1-800-742-3522) en español
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Accident Wellness Benefit Claim Form
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