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0000000814 00000 n 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. >> << /Count 1 /First 18 0 R /Last 18 0 R >> ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R
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CONTINENTAL AMERICAN INSURANCE COMPANY Post Office Box 84075 * Columbus, GA. 31993 Phone (800) 4333036 * - Fax (866) 849-2970 SHORT TERM DISABILITY CLAIM FORM *Please attach paperwork for any additional income you are receiving during this period of disability. /Encoding 4 0 R -8KU)@AZCLegJ8ge%BBp0g(_Y&;BmiFJfS%>@Gu7. For step-by-step tutorials on filing an online claim, please see our claims checklists. ["`,abhS3LE"C=T6]&k%"Zl4BdN^JG3F!Y*CQe"Xqj-
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In NY, self-funded plans and absence services are administered by and insurance is offered by American Family Life Assurance Company of NY. qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib
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<< /Creator (OpenText Exstream Version 16.6.20 32-bit) 46a&g>*Zg/Di4fH;%L. In New York, coverage underwritten by American Family Life Assurance Company of New York. POije23\6G%qCTitHV>Xor,
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If you disagree with a claims decision, you may submit an appeal citing supporting policy provisions. View Site Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf 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. $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K
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Please fully complete the claim form for the Wellness Benefit. American Family Life Assurance Company of New York | Albany, NY endobj *-ogCe2UsEgf\'ds_/jiZfh5I(c[]]fP=H[DUhhQ4'/;X2hk?KsbO!`rDQ2eS&bFI1P0&@J-^!k9`KO(igH\q^TX%?G:9)
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A&!R^maAJpBZW3)>! PDF Short Term Disability Claim Form Instructions Manage your account, submit and track claims, setup direct deposit and more. >> Short Term Disability Claim Form Instructions Aflac https://www.aflacgroupinsurance.com/docs/customer-service/claim-forms/group-disability-claims/disabilityclaimform.pdf Note: This form is for initial filing of a disability claim. ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(;
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#DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! Get more info about Aflac for business owners.. Aflac promised to be here when you need us most and a big part of that promise is making the claims process easy. Aflac Group | Columbia, SC >> /Subtype /Type1 ];]KtG'T^mQ6k\65n-CO3CpUj:9mE5T+QAa^Vn$W>6ZWQM=\_oAF,SBqE
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No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . endobj 34KC`g@bObJ6!O^[4KaLHd&d3Z>1B[8K]!Ma[U/7j$GS6:@5eWk>jl+X?+>PG9h*%gY?g&"\0cQnsu>;4$NAR_h9iPdY^EdXqEH&r&?URsH:@b+fJ3ul5P0*OfoJU+qB&mF'>3T)PgN9! <> PDF New Claim Form PDFs for WEB - S00224 - Aflac 0000049332 00000 n endobj endobj 0h_D=!TqJR_)(mgd\>#ol+75J9jtBIKFJ@V(i4JVZqc++3o&'Oo?S]N51A'u=i0pZ1o;C9[qgcc?S#Dh
/CreationDate (1/24/2023 00:45:44) A BenExtend claim requires supporting documentation for review of benefits such as an itemized bill if there was a hospital stay, itemized bill from physician's office, surgical report if surgery took place, Xray/Diagnostic Test reports with dates and charges if applicable, accident report if applicable, and a signed and dated Authorization for Disclosure of Health Information (HIPAA form). S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/ai^g,u(4jLe=m[4V59--p2Tap(*UC^8Qur;jVC%5c7VaBB+,0AUKH@dUPF5MD
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Open the aflac initial disability claim form physician's statement and follow the instructions Easily sign the aflac disability claim form with your finger Send filled & signed initial disability claim form aflac or save Rate the aflac disability forms 4.7 Satisfied 292 votes be ready to get more Create this form in 5 minutes or less Get Form ,-TQAaYC[5-ru"XbG^9qf`7Q_V*TD8eW0!d4tTL2](RU^lH!V+k6L3^9)d)_:\E
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Dental and Vision plans are administered by Aflac Benefit Solutions, Inc. << ?/8-TEfAU,j[:b-G[DjC57H"+$-Ag(@hZ
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Claims are subject to underwriting . View details, map and photos of this duplex property with 4 bedrooms and 2 total baths. ["`,abhS3LE"C=T6]&k%"Zl4BdN^JG3F!Y*CQe"Xqj-
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<> 1g!5D-LsIWRBY-X(8X2r&@O_`0*:d@O.-Wcm!Ja'h?grDR1Nq&[A-=2b! stream To have your claims payment direct deposited, please download and fill out this Electronic Funds Transaction Authorization form. ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d
Choose My Signature. Please provide a certified copy of the deceased person's birth certificate and death certificate. h.*.:`/`($FjUjeMh+%3^KDbf? 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H? >> 2 0 obj stream [P'])96k0r/j-O-5R.B+?Ujtp8t.Wa^\9uALh!R/l:Z3W3Fi9-eo;Q)?QN/coX1HH='4^
We built our online claims process to save you time and to help give you peace of mind. a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. :b_AV)1V(ZcOZDX/m5A*jYG7Ls#=[g?T6ig2h"/>:-ToJWI)s^O
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)lM~> m);lB2NZG/rMHahB@? 0000000009 00000 n 0000001020 00000 n endobj endobj 0000054923 00000 n Please provide all information requested on the Insured's Statement portion of the claim form. A(lCW]h%VdMt:8Y)JTJc(@p\,K2F73Vt)lr]_VGs^b4MoT7ZmT:ZlP&6C?-PWabHK;JrCnJnrcc
.8k,%=2e-? If your certificate number issued to you is in a numerical value, Example: 1234567891, please only use the two forms below. GgU]JcO2rI@MJ!M*4mh6R`a.PLnCe-ET<>a;*-c;Tf1f
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)lM~> endobj This form may be used on all product claims except Group Term Life, Group Whole Life and AD&D claims. 02rhl21qBSA"(T]mcU-(M+$l6hA!\lUur6,-iT#]. TLFC\4aS)n5C^j*@4%"P0VVa9rj(. <> endstream File a Disability Claim File a Hospital Claim File a Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claim File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company Claim Aflac Group Insurance Additional Forms Authorization to Obtain Information Form Direct Deposit of Claims Payment Form Please provide a date and complete description of your accident. %%EOF, smuq7OH`g&f1$LYcjY7O,U0QT2BYHr_p^&[03aUoihTl0LFDN.ikW)D+ZecfR[[u4*@bg/rWb0P936uUo^J$CLiNn/3c].L=V.c). 0000049332 00000 n nhH(@HB3(k..$A&2I&hNumCF[&]PjI*`R_D2M6]X>#-E#f;915&(PF6%>9Knd"E.:PO