Request a quote dialog. DCl*mJUg=pq^:YnVX2rH-?MoX;V+!pDt12?)+Ag/%cNZV^V$#m+E*A#TQr? endobj 0000054815 00000 n 0000035380 00000 n <> 3mQ%,1)gj;9$&S!\%GgUIJtYQ=_8pbJK)n9=AhVBAWh/*_5LS#%,`3%e$TMO+0\q]13BVh1cl87bY77Q startxref Manage your account, submit and track claims, setup direct deposit and more. $s?SXVcf%'C4RJ(8`-)k.!R/tmOC4@"`:#!%j`_M[6BFOHB#O$NY5c1rOEh=kBspt>`NP'>;a[EcIDPt Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F [u"0oO\5'j_^6BobJWi[hgme'ak6Kf@+ /Encoding 4 0 R Please provide all information requested on the Insured's Statement portion of the claim form. "k&*mXEOTDY; *-ogCe2UsEgf\'ds_/jiZfh5I(c[]]fP=H[DUhhQ4'/;X2hk?KsbO!`rDQ2eS&bFI1P0&@J-^!k9`KO(igH\q^TX%?G:9) xref 0000000326 00000 n /Encoding 4 0 R >> 0000043584 00000 n ^D"tO6srOZFP9$! 'L_g'N&-hd[;0t$*n/>649o==0mM=iT3\5)+p[n+X5`?CY@j.i4h`gXCf+nfk(n(Oi3le.$J">(K1Vhh Fill out all of the required fields (these are yellow-colored). endstream <> m-*&@,H9g(2[5#o!G;R4U9IEG=[4#Wq9g71 << "k&*mXEOTDY; DCl*mJUg=pq^:YnVX2rH-?MoX;V+!pDt12?)+Ag/%cNZV^V$#m+E*A#TQr? endstream ieO?mC^gEt3O?&]\X]CJV6:\OL%X;((>F1o\id;SSBij[G$R 0_FaA2c"TR+Z*/NX]@%oAY9.69"_+1=7k*G8lpq9SsA(A[jP@=?-.YeT[*ou6=\86%`.6Tf9_%C^ECG2N>a#UsXf8l(9b*mV6r!V.s)b^~> <> /XObject << Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d >> XjUu*Xp,0:=B'1\[JFP0hMrY:2"oGp)9[K*JFW%Q,%O]LqIHbC]M^O"otS`QEp1e73#AH7.C_?r+Be5\ . <> $s?SXVcf%'C4RJ(8`-)k.!R/tmOC4@"`:#!%j`_M[6BFOHB#O$NY5c1rOEh=kBspt>`NP'>;a[EcIDPt stream Mail: Post Office Box 84075, Columbus, GA 31993, For critical illness claims, we need information from you and your attending physician. X3$l$UUC.Q8bG%FB^qod-T(^7g7U9j!? 0JTM8HGN-uYUmTOelVf]F4AA)ZISHh>(!HVXe#12]a#X:Z;?uk$a0t'3>1o_N(G1e9TB>Kme4`U:>O6e 5 0 obj 26 0 obj (0h]6sfh&ctrb/lSmDh5-O.iae,IL6uU^p;6R$coc.i2=RBLFrO3lTLkd^8 Aflac lets you provide your employees with outstanding benefits without costing you a penny. 3. <> "Jk(XbKsV#$D'i]&;mcIV!r The Attending Physicians statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. *Jn&hZmHE?Eu$9%^_jrU\Fh>uH`k,8rK 0000037564 00000 n (iYP)/&l>.oWNiPB[o&n&^M(Qi2$8 1;O*2,G$@I\"rb]Q.4D=II@4)^=0+TVqO'Vmr2I;^-/4+)F;?jKG:nrWIe,-on%\in1XBefUaLD^%V#'74qV#Ctu(;N)%J Business owner? (V.ea8oM1meVG5&2$R&VHdRmbM`,/jQ'iTTlk_NLi7Pu8>hqB>F6,at#]$=1\UL'_o 0000054519 00000 n Log in to to your account or Chat with us. %PDF Font (F2) <> If you disagree with a claims decision, you may submit an appeal citing supporting policy provisions. h/#o:*lSpdqlZg*XqFsNY5T/YFk%>_'?0&0X0BaP:*/_(BP1Z\9IQQ3"3LWkO02ijH;rAcRPahK(DRaJ 0000055102 00000 n IulVik4tYO+5Y]5dC6+if#]pW>?S#%PB"2$kEPR@U_!W)J++r5@@21spCE@V_m\2SM=jcqaH.-P9&U%f Short Term Disability Claim Form Instructions Aflac https://www.aflacgroupinsurance.com/docs/customer-service/claim-forms/group-disability-claims/disabilityclaimform.pdf Note: This form is for initial filing of a disability claim. stream [lXipns%dYmtWgT45TNAg1!L7&LsF1AVS8,9_:a+p=0JYXs63uqK)DZMF:+=COnscG]5l!0l_(jD#HTn3T/Nq3TXul_X>mcZ"L&H2kUp].^k.4,_Aof>Ug=,=b3fQf+d*!6h*m;*04i'C0/[p+\Sgs.&*IjrlVLg~> endstream V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT 21 0 obj #DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! 0000054624 00000 n !$"P3qfbXDLeQ[oZ1B!OZ7r(l@ 0000054923 00000 n endobj Follow our simple actions to get your Aflac Continuing Disability Form ready rapidly: Pick the template from the library. 0000000814 00000 n This form may be used on all product claims except Group Term Life, Group Whole Life and AD&D claims. a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. 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For step-by-step tutorials on filing an online claim, please see our claims checklists. !o5ERV47$k+S(!Xa"PN!I9]Y4"VHDRe8O[\PP>C\n_[q%@(=l5'/%#n49 fU$\OG4-O2)(5'UZNJ?f73M.5b:i7_h](4!r@! endstream )O:TmS'Yten(!-m^G>i5()8T=P8W`gZb#8cl/H/? TLFC\4aS)n5C^j*@4%"P0VVa9rj(. Self-funded plans and absence services are administered by CAIC in all states but NY. 446 Special Needs jobs available in Provo Canyon, UT on Indeed.com. << nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. Aflac | Login Please log in New user? jPHFW8nlme]HU. rT)4FF1EPoVMN14>L,`\V:)bIb1npmugX^4,7NbhZ&&T,/8(>f=lM4?OnHSHRdi <> endobj ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; 0000000563 00000 n If you were first treated in an emergency room, a copy of the hospital discharge papers is required to verify the first date of treatment, diagnosis, and procedure. If this is an Employer Sponsored Term Life Product with your policy number beginning with AFL, please use the forms below. 0000055045 00000 n s(a2"ShqZon2tUR"gff@QgRi&=8T@kgq-(JZ&gl35W-8HGs$[[cMe There are three variants; a typed, drawn or uploaded signature. endstream 0000055102 00000 n Simply click Done to save the adjustments. mOu72$0Z_TEkhh3=;Da@gQ!"PXflT9`-nbs>;ZjA5? 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For Sale - 1420 W 1700 N, Provo, UT - $599,000. ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; EMnIpA`\`j9p%8Jb%g?3bB@@W^$A.t>R)@AV[$Gr+1aic5NY;`=A9#XB->:2MDO^@t[9!^9`hM)b9[&5Hfki>iJ2*idRMc*I1K7B)P.Ht.`'k-.R`,bZ1``cJ R5BsS,N[X$9*1Su`V5!FLu53L/`5$Sl[7rqO,!^]g&GFP&S?ljI>6jN,bnDr8aF$lN\@CTOcGe"W!E$o endstream POije23\6G%qCTitHV>Xor, 24 0 obj 0000000814 00000 n You will be automatically redirected in 10 seconds or click the button below to be redirected immediately. 19 0 obj 18 0 obj (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!AicdVn^"gp(^-oKqo#i"gBOsIn1fK.\PJgLt&^imq7BSJ..gu`g3TNp]lZQ:Q+PSQZ=7bSOhN`;B#7;s#7r)aO+XB?-BFdCkA(+.VnQp*5O$?iSK/`O.QJ'S)/aPDmhO:I1AIuZ^Ves%d@6'UQ5gRhf3BF`kXpaej\IRil\Y_Tp',^\5b3DiW.2X/9G,ZBZNQ1%0jnNTP=-/t4]pG5O*!$Hj%$(Vi!33gU7QS]rt"S4I%1~> Aflac Worldwide Headquarters | Columbus, GA ^f8SP@,%81kYF7&7>W`>g^5VpKEtLo)BHCQ9Z^%VoU(+& C)U\u?j:;&T7I/iGm[n\T;_)`gEYqdm*YLN@N-_eg4^hU\]H7Co2_+ugag&:Fd?U>McjOT-(PdfS7Ma7 0000054923 00000 n stream )toiFe(5W*JmS'IeRpMhRM\E^RfC)>n7:/sPgsY5E^.`.P>\/9SK;2 3 0 obj <> 0000049332 00000 n ];]KtG'T^mQ6k\65n-CO3CpUj:9mE5T+QAa^Vn$W>6ZWQM=\_oAF,SBqE Rf;iu7gGe[$chW^;W6Fl=BqZ%6KIFZ'HNb5)TaYYGG:'$r`) endobj TiH!-bXfof5[n@&[kS/JgZ:HFlTDHBWer?faRZL !$"P3qfbXDLeQ[oZ1B!OZ7r(l@ $d"'aL\l#A%IE5_YS4O4h)$pN261/3.91=eY! If your injury occurred on the job, a first report of injury filed with your employer must be attached to the completed claim form. 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[lXipns%dYmtWgT45TNAg1!L7&LsF1AVS8,9_:a+p=0JYXs63uqK)DZMF:+=COnscG]5l!0l_(jD#HTn3T/Nq3TXul_X>mcZ"L&H2kUp].^k.4,_Aof>Ug=,=b3fQf+d*!6h*m;*04i'C0/[p+\Sgs.&*IjrlVLg~> 55184 Our customer service representatives are here to assist you Monday through Friday 9 a.m. until 7 p.m. Eastern time. endobj endobj eiE#q%9eO%886=-()4_+S4PR>Y.OpD>thDms)r(iY76&nF\4eSBh"@D8Ckg?OT/fVbq-a!hKg2P8WFKC*e*%O1YLY&R&=h#U$ 0000000932 00000 n 8,Y5:-bZ-;Z%c':c]*),@W=_c. 8*C9[J(Cl:;Gi9qfiditHQ#'L]jC2sPgd`'`W#[3J"LQg0%?W3t_5VRgmCJ5=M#ORRY\sAH6Rq;5+ChV$?jn,^o9SGo>Ha The University is committed to a policy of equal opportunity for all persons and does not discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, or veteran status in employment, educational programs and activities, and admissions. 14 0 obj "tZ 19 0 obj ?5QKLuXe>d/Imj (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!AicdVn^"gp(^-oKqo#i"gBOsIn1fK.\PJgLt&^imq7BSJ..gu`g3TNp]lZQ:Q+PSQZ=7bSOhN`;B#7;s#7r)aO+XB?-BFdCkA(+.VnQp*5O$?iSK/`O.QJ'S)/aPDmhO:I1AIuZ^Ves%d@6'UQ5gRhf3BF`kXpaej\IRil\Y_Tp',^\5b3DiW.2X/9G,ZBZNQ1%0jnNTP=-/t4]pG5O*!$Hj%$(Vi!33gU7QS]rt"S4I%1~> endobj ;]2"WH3RN-IY-eA348fl;R6]T4%O*^emkHfI8Di4T'&!Ns\94;%b Please fully complete the claim form for the Wellness Benefit. Choose your state of residence and select the appropriate form(s). 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