aflac disability form

25 0 obj 24 0 obj !7O$KXr'tSP>! &>7[>d7(qqN/lSW8,9((\,+tAibO:g1>Tl'K;D\HUqeC^#X0pPUXu3oeqYppd\O0nI(-OoF3]X=)@;7_ Do Not Sell or Share My Personal Information. stream c5lMh,QXUsVpDOgY[E488MHV?GK9DUk^qXiSo6?d"#T=f:;YTi0SU1_S\M2I.26bpPB\Xsl"fN>oQoH- Online Claim Form Aflac https://www.aflac.com/file-a-claim/default.aspx Use Aflac SmartClaim app to initiate your claim process online or track your claim. Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the, File a Hospital Indemnity via Fax or Mail, NY - Accelerated Death Benefit Claim Form, NY - Waiver of Premium Claim Form-Initial, NY - Waiver of Premium Claim Form-Permanent, NY - Convalescent Care Benefit Claim Form. )O:TmS'Yten(!-m^G>i5()8T=P8W`gZb#8cl/H/? No Yes Isdisabilityduetoaninjury? X3$l$UUC.Q8bG%FB^qod-T(^7g7U9j!? To file a claim, simply select the appropriate claim form for your specific product and mail or fax it to us at the address on the form. endstream Q[WGEfLmSJlD4aAIQg]>]O"6oFV!6AQ*&I%W1?E?iS+o&0c^Yc&U1]$I6mp;f=sCk)`?#3^FVJTgJrGe_1^q4-mOnYK@c1T5eKoO`M^;`6u-:]MC=Xh]*G+XUYfH(M?5 '1L#-Ne#BOUYn.SL> %+7qEQTFU"'i_\(/=gq+JNS@%Y-$pZB>:Y4*(rCZfQj@Kgqq^GWEccM#up\R$:Ie]Cf@mqFQ&(pWqBMr /Subtype /Type1 xref Use the Cross or Check marks in the top toolbar to select your answers in the list boxes. 0;p5g%:Gd\>Io0dB\q^f8G>h/i$&$eAg8lGgN!bHFN/%]=BXD&^?mb,/u7t)rbDTL)pZ8Q"RdB*(8=i? Then, follow the simple steps below to begin the claim process. endobj )F9)MP$gjIIV>!H Short Term Disability/Long Term Disability Claim Form. 0;p5g%:Gd\>Io0dB\q^f8G>h/i$&$eAg8lGgN!bHFN/%]=BXD&^?mb,/u7t)rbDTL)pZ8Q"RdB*(8=i? A&!R^maAJpBZW3)>! 1g!5D-LsIWRBY-X(8X2r&@O_`0*:d@O.-Wcm!Ja'h?grDR1Nq&[A-=2b! ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R <> DCl*mJUg=pq^:YnVX2rH-?MoX;V+!pDt12?)+Ag/%cNZV^V$#m+E*A#TQr? 3 0 obj m-*&@,H9g(2[5#o!G;R4U9IEG=[4#Wq9g71 0000000814 00000 n $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR stream pVm0rYNePYi@2CrKlf(0`O9(:4lsA`"DB*V_2?OtI(:IK1s$SV]W0j\bo[2VhWP2Ff.O9.oYUrAMp$ 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. 0000054442 00000 n GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. 0000000009 00000 n 0000000212 00000 n 0000000000 65535 f ;dps@dXdX$3sN65dLrqK;34,XZ>#G6k1;= /BaseFont /Times-Roman ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! 0000054815 00000 n endobj R5BsS,N[X$9*1Su`V5!FLu53L/`5$Sl[7rqO,!^]g&GFP&S?ljI>6jN,bnDr8aF$lN\@CTOcGe"W!E$o :^_n)prV#UtcF7_C)h7^7 "DFX!Fen1$B29'W4#sWKq 0000000326 00000 n qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib -_6'A_4IL[`92un&r8tH[>^"rhOWrgJZC\%6"6'k2kR6&.9EYCGWVonkFA2[(WQ.mndG'-IoKK^(VM6j):K)HmcRL+qg#Rf 0_FaA2c"TR+Z*/NX]@%oAY9.69"_+1=7k*G8lpq9SsA(A[jP@=?-.Ye> :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! The Attending Physicians statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. Please date and sign all required forms where indicated. endobj <> O!61!%9G.V^/"+$60K[1j:%8%V^jr#WgA)E0dmgaHYP)uTIcfaXm(sZ9L'dZ;nA@OpWjJ1,O,)*$t/$< m^PaP#$T,QfVQ'7kTb=#ja*O^[oT:q1qW?WH%a_Lp. 0000040092 00000 n "DFX!Fen1$B29'W4#sWKq 3OKN&2W(XWj*4Pa1H50U%qWra$*VdVbd3"%Mqma1p?g8L8>2.+8'p^s14V/euOX@S5` 26 0 obj endobj GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. `JaOS[A]]e$%M7QS4Qo!meJ)_CS:m7V7-aS4FZ1PGi:"6tO9;>TbWc_tC3LGp( endobj /Subtype /Type1 0000035380 00000 n endstream nhH(@HB3(k..$A&2I&hNumCF[&]PjI*`R_D2M6]X>#-E#f;915&(PF6%>9Knd"E.:PO Once completed you can sign your fillable form or send for signing. endobj 2"3sWA960?8;mmK#ZE2_=#C>QJ%q+@gg/`.\j'lY3GBQ_ecS2/`]F/b3$3maOCefRcJ`5!g@1,GaV\/9 And the best part? << /Count 1 /First 18 0 R /Last 18 0 R >> Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r /Encoding 4 0 R endobj <> )toiFe(5W*JmS'IeRpMhRM\E^RfC)>n7:/sPgsY5E^.`.P>\/9SK;2 C)U\u?j:;&T7I/iGm[n\T;_)`gEYqdm*YLN@N-_eg4^hU\]H7Co2_+ugag&:Fd?U>McjOT-(PdfS7Ma7 Gb"/,=``@V')jD/9@r'LI-A9Cs4QG6aPLKNd:@s1MX5It9Jnu*B"qkR+QHs<2n)%/\Xan`a,N@6*ingN'+f$>Yo4]C!mu:p`lCe=FLB/(I,"jXamHKJNR+)Gl0L9$(Q$m:^j,14/`h-mD]X`XMK+=Y,,E.#`="+f8AJYrKUGA5Q"McHIugr&gV)sipH;3V;[q7F*GJY%abm(8>b!Y>#S?Q?en;S)"OEiMWIE&0@qh;EHk*_:=;gW4*><30$L0fSkD:d)2[Y8SYpcUZmVX";D!VFF#NjUnu/i=(eN%U3gqf'WI/NZX5pMY'?GQ)r4VCNI>8uDZ9$#H/kaQcLFj`bUB3^t!`Q:uaAT(ea1%WFIpS6Ag:?>H$75dihDjh[BEL"?jPA)pe]F.YplX)@3j98ARtS-K?QMb7,!]b.D>VpVJ$.D,Cgnh]1J7T(AtopjVlaB^!.A26henEG&.OY;@Iq.U(;Viu(HKO$.\K*8Lk^]!(LVMX-[0L]OWdQ5O?*Qg6:M)P^@ai,(^_E!:Iq@eTnj3uRVpK]@Or/E+[-a7Dp>u^OF%E]LIm[rs(u=5^p\I80PCZ8,!eM\4J4j18:dSOVOU6cZ[#)7UXXs5pjV;9['\gDTUS6EdKO#QZhq:bWR?R:@4Y8CQ1h]L`j6s02no<6g[7i(GO`Q-$7mHN=/n:Gf.H@)J0"*O&:6O.K18Wn33WAg;s,d1LUJO%Lfo4ld_7CG_g\RF[0d-qmdP5,$mH-h*Ula*D+fdn$e=XEOMub_:t*%ti!>W,FhJC&3*L=^)sJ%F;NO"C9[kluU]cc98X)>X"A2]7JD"#9Q(eSSX<2hiWOMu3c*3Cl#A.:WQKCi-LU%^3>#DKnSAK:Z0%R4F:$c,fB*LTO?$D[Y9m;(K*!bMU6i&L`h@5#$fCr!VJ)*$ApDE(Iaqq9p'5JJ$OWoHV-lnT.-#2ji?i4+(+-+=[%\t6Q3*F98'B&T>Z*VMs7:^kaickW#fPk2Q*ZN$"Y`Nr/T3i]pS_d'/qC"V#!L/GaW.3?1m>ardXNjcoog4djTG`ic)$u]?!eWPbr'fHgEr8(.*8)`VFA+1+&Q(+loBW0XJbQM?jo]j+#?f9G&OWPngFMU`0-ca8t`Y_M=#'e-/5ML7(pOujXrD!i_=hH]Zc_qn\.[1gGs0mja.PjIs!ADVNeLpg=>In+L3_@6qp\b9n:']BPb54)0k*MbY:pCGSiU:3QVoKQ0\Wk2RLct.[c`u00c*@8)QIh!i+b7m\P/AI`r7[X;CJq^2E>(5VkU_!Uj(T&UOo#8W0VDZuZ)L$X=CR_b%Oa#Dm`111Z\+8jOOpQ@&S(k=UoK#^`h;l/9(u.UhAop*mif]!;3AU$'ES?+\H;6,nHMla1/m@$@ca-)N],At$)a\>/XK/,b"h&j'0ao-NK\2:@$%[FjE-t's1.SnVk>de!\EUEDA'T3&fEcf.#1SRd,b\P/X[i=;M5sl&as4--!?pBU0"&M,J1g]NZ%tN*jgu`"0stJ>f_IdaZ5>Z[>PrUj*j5P5-IG?GAbRqgUUO/cMr6O.IX*d"jWW:2T!&@.[^$62E;[R#+$%EkHYm.Y9["e%$KpC!=;@TJ9kVpHj8/iVY@*E2Z'(6%@U'<8%t\pU6nNS"Ejf5Fu?IU)3/WcHdCK/o&mJN^j-hkUE@DmK-,Dp5:2B/ne3e8>Ts)\o=e_\cVbi,f27^E^`bVn.p)J\;WEJ4DL1`D^Mj$V=VSHZRmD=Dk`)(cFFZ@L/E1nDr`o-LT6QMF'sE_=(A2qGLc*q`Sa+DZa,Xe$IcN-m#P%,0"EChMpf"@;,QSk::895BW(XUgt\_^4"1u:51R+Vp*Y_4i9Vr@Q-=:IbV0d)!Ah@!F=lBtn?@CbY]KE(>R4^R')&bOtU5h^S_s[[dWp;jj*Wi'RU#2kj_TgQje:jfNsB94%sEq&6n&]"%SF/#Tq(>'CjmNcqaiaoB$nY>=+tp.eNHLihdu74M8'^7l)TrY.8r=dg=lmT"7X&N_32[kTN`tl:-DT%LHVQp-M/g-;E58'_u52M&a0mK7B(@WsPYA_T^J%qc8K#+e,BM0Q:NoU2`^1">ha,s#H4G*+sdbU0(\t=PtugW%^$om3$gbc6[$3k9R:&F(7Yjj[d6f#I=(pU&hs#F]5_1#;9IE8b=Vm'(DC0!J-h=$,TZ2ZYiSSOe#)':%`OXse?NlTjT?4\778O?BBCK(K(8@(X=Vm.@8VEJNnD0*JL6>Lpj*;W)VZN'ORQ;GI:cq7_/KGm1FFFeH"0FYPdf!ZlcLY(3!AP+&BD)ff:8-UUd.O^)"PkMG[Iloh%=Ouk64%(L6ki;N_PqGLfpLgcgc&3M8XS^V`NJ2Z4Z/RG3D!mY"kLYVD>BY4[$d\^;!IRbt9i59mQ!@0s_TT_t+0=N]=K3luI+\(XfQ5e]5Y]q@ohAheJYVr>PF%OQCE86=gh!N`0L*^6_:QP?6u0r5%1hGWbC2_HPB4MX[cGE(9q;LO0fdX7\GmZ>>,\&:/tm\-t*OtW9\3/6\.A\6ZE8S%\So=R&Q]MAdBNSon:_JPqng:h-/j9AtJlrs2/=Ai!`(XA]<=>\>d?'auHY^s[UK,m!(>[:Pq]sS[Bca*GgBYh*1dE(%hE&QFc^dIdG#.H18:@0U,pbR1i0OHr%ZD%"dUD1"DuY4>c0PkmD1%2p#>4jE,*9"aVX9!`oVXR;d-Y3"Hq'?Sn=O;D/S!.>c4I`[@q^TH0/=d^]h("acNGHGDT9WS#ud0uPjK+i_$C(k.jXdJ36.nq.kcQm]seV);aZbO\Ir%1_ADK;E@NjCXla+i4-#d1O[jqH*^qL\^[c.1O'0C_rHV&m^]$\[[eFQ1TO;o>>(Oc. endstream endobj /Type /Font Group policies are offered by Continental American Insurance Company (CAIC). 21 0 obj m^PaP#$T,QfVQ'7kTb=#ja*O^[oT:q1qW?WH%a_Lp. 1g!5D-LsIWRBY-X(8X2r&@O_`0*:d@O.-Wcm!Ja'h?grDR1Nq&[A-=2b! 0000043507 00000 n ;dps@dXdX$3sN65dLrqK;34,XZ>#G6k1;= 23 0 obj 0000054442 00000 n endobj fKM7f%?5*K:i'+aV_K!?49DLRD(oBT]NI)%kf!BU%-f'rI-kJBX(Gn\B]/9qU,\iQ;,gU.Z@%@^>"[]W:T%89f)q@tlS'SN77! QE4ts8i6DE)#'2TW-kh'[,&7Z'RGbFcbLB$$`BMM!R'_,b^D2"+(\! For Claims Before submitting a claim, be sure you have communicated your need for leave to your employer. Aflac Continuing Short Term Disability Claim Form Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf Please note: The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee's Form W-2. 0000055045 00000 n 0000054519 00000 n 0000000446 00000 n endobj 0000037564 00000 n ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d Bk\1f/VUX4ST4NT40lN34+-*[pI_iW#ggd2*`hgWE^=-R:s=)2'tu01Vr]^_S>-&.RS7)o+'X@(Y83/( <> >> A(lCW]h%VdMt:8Y)JTJc(@p\,K2F73Vt)lr]_VGs^b4MoT7ZmT:ZlP&6C?-PWabHK;JrCnJnrcc nhH(@HB3(k..$A&2I&hNumCF[&]PjI*`R_D2M6]X>#-E#f;915&(PF6%>9Knd"E.:PO endobj 0000000326 00000 n endobj <>stream !7O$KXr'tSP>! 13 0 obj 0000043507 00000 n endobj >> endobj American Family Life Assurance Company of 0000000686 00000 n 25 0 obj FuFfnc;)7cKg['Zqu$@#^.Lm;P)OIh\R^_`-@):D`Br-$pdOd.\.5Vk2j_jL6C'[%-[(4 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H? *?ZgaJ72F%->d4aYIUb3reE0'[sM)3JY+[(7="R\fM6;Q Aflac Short Term Disability To sign an flag initial disability form right from your iPhone or iPad, just follow these brief guidelines: Install the signNow application on your iOS device. 0000054442 00000 n 23 0 obj CNbe58Z\L9(JIf#nd8N&d;_Ve"&$B6Y;]TiZ`M2[D^dN\Eb5qm'qVJ='T'4DBH2tpG-/Q,o_g=%ZaF:Y 0000037564 00000 n <> k0Q'9K%4rkrrN3]cu8p8';m8q-eHY2Sa?q0DqdO_]i_5()gWNP#-%H8k&XV=Id,j>)pb@S-4-ot]OZm4 93^8SlqmQZ!1De"\u*GfeLd;np?nPWYSd67)d]ch=uD%XiFi:dZhC'MhDK8OlZ2*YHmB.O$)Wh[*"R,, endobj P\D=1Pt+K^bCr/L=R_+?]7:K8ND*^rZJ>\)+SO$sqSJ1VT+A'Q-ShdfdhK\Q%N%LoP*mTJ1U1["BmoP?0"U1GH. @oGDmsuR- View details, map and photos of this single family property with 5 bedrooms and 3 total baths. *-ogCe2UsEgf\'ds_/jiZfh5I(c[]]fP=H[DUhhQ4'/;X2hk?KsbO!`rDQ2eS&bFI1P0&@J-^!k9`KO(igH\q^TX%?G:9) IgeDH7TM\#pU10L#Ss`6=>>>RJf3(u"SS*/4)kIZjBeggFpXisbnT"]8aV=2.gG!O"):K$0*DuMhDAGnARk37 >> . $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR ];]KtG'T^mQ6k\65n-CO3CpUj:9mE5T+QAa^Vn$W>6ZWQM=\_oAF,SBqE <> 24 0 obj 0_FaA2c"TR+Z*/NX]@%oAY9.69"_+1=7k*G8lpq9SsA(A[jP@=?-.YeF*fbNG$7H6^5^trSgt@MX18^JE+B$K endstream 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. R5BsS,N[X$9*1Su`V5!FLu53L/`5$Sl[7rqO,!^]g&GFP&S?ljI>6jN,bnDr8aF$lN\@CTOcGe"W!E$o Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r <> Please provide a date and complete description of your accident. /BaseFont /Helvetica-Bold POije23\6G%qCTitHV>Xor, 55184 Dental and Vision plans are administered by Aflac Benefit Solutions, Inc. _0kQ98&!$i3)qj(aoD$GE4ichZTh10fLUX?o`T)Tp(DKE$D,A)o)nXcqGjE4Kf$SW?d(38p]9$)m%!a_ 0000001422 00000 n 20 0 obj <> >/FRGOB+OB[1iVR22-7Lnt@)K1T_gY[7;kiM;`1C&61:AoC42ST7*!-T+uZ3:t]s'Eh(_u3^02+HBBV< !o5ERV47$k+S(!Xa"PN!I9]Y4"VHDRe8O[\PP>C\n_[q%@(=l5'/%#n49 02rhl21qBSA"(T]mcU-(M+$l6hA!\lUur6,-iT#]. Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F endstream ;PmE,29/@]Q_gjie3>F*fbNG$7H6^5^trSgt@MX18^JE+B$K 26 0 obj 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; <> !G5'>m!$kI`%E,=&c9e1!`-(ln6%1Abq7/PK2;m`V,'D51([Fj ;]2"WH3RN-IY-eA348fl;R6]T4%O*^emkHfI8Di4T'&!Ns\94;%b ?5QKLuXe>d/Imj 0h_D=!TqJR_)(mgd\>#ol+75J9jtBIKFJ@V(i4JVZqc++3o&'Oo?S]N51A'u=i0pZ1o;C9[qgcc?S#Dh !G5'>m!$kI`%E,=&c9e1!`-(ln6%1Abq7/PK2;m`V,'D51([Fj ^$F!_M^D.n0(qARn(aE/AgY,iIM9"8CcNDqjSN*8m)"S@.f==Xc1]GcbA-_LZ\:A:pe2tj endstream D3IFAAEDU]W&`=8ZQHFkEqDQ^[Kaa=!=[XM/$T#Eb_7Ual%dq@k@o8>0@u1oQdW.1<0#6L^ZrQRcYr_T ["`,abhS3LE"C=T6]&k%"Zl4BdN^JG3F!Y*CQe"Xqj- a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. 0000000686 00000 n 5 0 obj endobj a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). 3mQ%,1)gj;9$&S!\%GgUIJtYQ=_8pbJK)n9=AhVBAWh/*_5LS#%,`3%e$TMO+0\q]13BVh1cl87bY77Q