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Initial Disability Claim Form


Initial Disability Claim Form
Initial Disability Claim Form
INITIAL DISABILITY CLAIM FORM
FILING CLAIM FOR (check all that apply):
Failure to complete this form in its entirety may result in a delay in processing this claim.
Page 1 of 4 04/09
_______________________ ___________________________ ______________
CLAIMANT SIGNATURE FAMILY RELATIONSHIP, IF NOT POLICYHOLDER DATE
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.
S00224
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)
Disability due to an Accident Disability due to a Sickness Disability due to Pregnancy / Complications Disability due to Cancer
Policyholder Information
(Please print.)
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:
INSTRUCTIONS: Be sure to include your policy number(s) on all documents.
Complete and sign Section A: Policyholder/Patient Information.
Your employer should complete and sign Section B: Employer’s Statement.
Your physician should complete and sign Section C: Physician’s Statement.
This form should be completed on or after the initial date of your disability, hospitalization, and/or surgery. Forms completed prior to the initial date of your
disability, hospitalization, and/or surgery, may result in a delay in processing this claim.
If you are a Contract, 1099, or Self Employed worker, Please submit your prior year tax return (Schedule C) and current year estimates
tax payments (1040ES).
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 healthcare provider (s) by requesting a UB04 (hospital bill) or HCFA 1500
(nonhospital bill).
Please include a certified copy of the death certificate if the patient is deceased.
This claim form should be completed on or after the initial date of your disability, hospitalization, and/or surgery. Forms completed prior to the initial date
may result in a delay in processing this claim.
Cancer
Policy Number
Accident
Policy Number
Short-Term Disability/
Sickness Disability Rider
Policy Number
Hospital Indemnity
Policy Number
Hospital Intensive Care
Policy Number
Life
Policy Number
Initial Disability Claim Form
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