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If this is a Disability Product with your policy number beginning with AFL, please use the form below. 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. 0000054815 00000 n ]_h\LUlKWpDX[03gS"tG,UJ0*mL9UkEk%7OIX,#u6?P_/\,44Z>m2`cW$i)b*qRV/6raU^h/W^<6?6JC;$U>eK_"kZBZcu]&\dTh"\!Q%B8?1?Rk8,^p^Wn[RC5_%c^'XQF+or
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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. (iYP)/&l>.oWNiPB[o&n&^M(Qi2$8
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Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). endobj 0000040092 00000 n endobj GgU]JcO2rI@MJ!M*4mh6R`a.PLnCe-ET<>a;*-c;Tf1f
>> endobj 0000055045 00000 n Create your eSignature and click Ok. Press Done. "DFX!Fen1$B29'W4#sWKq
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Policyholder Information: View Site Continuing Disability Claim Form Aflac 1;O*2,G$@I\"rb]Q.4D=II@4)^=0+TVqO'Vmr2I;^-/4+)F;?jKG:nrWIe,-on%\in1XBefUaLD^%V#'74qV#Ctu(;N)%J
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Execute Aflac Initial Disability Claim Forms To Print within a few minutes following the guidelines below: Choose the template you need in the collection of legal forms. 9srK>"cZ(SQ7f&_@XkjoOD9.JoV5["B)lrLk1"RN#NAQ@Io/k:h_VaFk%A]Xes%eU0Lr%f7V@nha@^3[
Please submit the pathology report used in the diagnosis of a malignant cancer, the claimant's birth certificate, and any itemized medical bills with the diagnosis and procedure codes, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). 'L_g'N&-hd[;0t$*n/>649o==0mM=iT3\5)+p[n+X5`?CY@j.i4h`gXCf+nfk(n(Oi3le.$J">(K1Vhh
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For disability claims, we will need information from you, from your employer, and from your attending physician. Please provide all information requested on the Insured's Statement portion of the claim form. GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. <>stream AkJD?1M>up>BcsX+I=_#LC$k%qGLcEUfd4i%!i&
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View Site Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf * Download the data file or print out your PDF version. $s?SXVcf%'C4RJ(8`-)k.!R/tmOC4@"`:#!%j`_M[6BFOHB#O$NY5c1rOEh=kBspt>`NP'>;a[EcIDPt
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startxref If you are filing for a health screening on your Hospital Indemnity, Accident, or Critical Illness plan for Coronavirus (COVID-19) testing, select Biometric Screening as your exam. << 20 0 obj ^f8SP@,%81kYF7&7>W`>g^5VpKEtLo)BHCQ9Z^%VoU(+&
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File a Critical Illness Claim via Fax or Mail. c5lMh,QXUsVpDOgY[E488MHV?GK9DUk^qXiSo6?d"#T=f:;YTi0SU1_S\M2I.26bpPB\Xsl"fN>oQoH-
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