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Accidental Injury Claim Form


Accidental Injury Claim Form
Accidental Injury Claim Form
ACCIDENTAL INJURY CLAIM FORM
Failure to complete this form in its entirety may result in a delay in processing this claim.
CLAIMANT SIGNATURE FAMILY RELATIONSHIP, IF NOT POLICYHOLDER DATE
Page 1 of 2 07/08
Please answer the following questions. The claim cannot be processed until all necessary information is provided:
Date of accident: Describe how the accident happened:
Location of the accident On the job Off the job Other (please describe):
Was the patient the driver in a motor vehicle accident Yes (Attach the police report) No
If the patient sought treatment ( 50 / 100) or more miles from his/her residence and required lodging for patient’s relative while
the patient was confined in hospital then submit the hotel receipt(s). Please check your policy to verify the mileage your policy
covers.
Complete Policyholder/Patient Information and sign your claim form.
Have the treating physician complete Section B: Physician’s Statement and sign the claim form.
If hospitalized and/or confined to an intensive care unit/step-down unit, please send a copy of your hospital bill showing charges
and the number of days you were confined. These items can be obtained directly from your health care provider(s) by
requesting a UB04 (hospital bill) or HCFA1500 (nonhospital bill).
If you are filing for disability, please complete the Initial Disability Claim Form (S00224). Forms are available on our web
site at aflac.com.
All bills should include the diagnosis, services rendered, and actual charges for the service.
Policyholder Information
(Please print.)
Policy Number
First Name Initial Last Name
Mailing Address
City State ZIP
Check box if this is a
new permanent address:
Social Security Number Phone Number
Patient Information
(Please print.)
First Name Initial Last Name
Relationship: Sex:
Primary Policyholder Spouse Male Female Patient Birth Date:
Dependent Child Check here if dependent child is a full-time student (if over the age 19, please provide school name
and contact information).
S00198
American Family Life Assurance Company of Columbus (Aflac)
Attention: Claims Department • Worldwide Headquarters • 1932 Wynnton Road • Columbus, GA 31999
For information or help filing your claim, please call toll-free 1-800-99-AFLAC (1-800-992-3522) or visit our Web site at aflac.com.
Toll-free fax number: 1-877-44-AFLAC (1-877-442-3522)
Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,
which is a crime, and subjects such person to criminal and civil penalties.
Accidental Injury Claim Form
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