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Your employer is responsible for providing the information in Part B, and your attending physician is responsible for providing the information in Part C. In addition, please read and then sign the Authorization for Disclosure of Health Information (HIPAA form) included in Part A, as well as the separate Authorization for Disclosure of Health Information (HIPAA form). Check if everything is filled in correctly, with no typos or lacking blocks. a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. Yku1YRdk^9;TD\;*kl4jYjTa8Xl"SC:fUS)e;!AcrDK#l16`LFaGhEJ;`,G>'H*8^Jr\^>/E?FZ]1S?b
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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). h.*.:`/`($FjUjeMh+%3^KDbf? <>stream @lR;bed"/KM4=.N)6,FfJ&AfVrJm-US
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Direct to Consumer Business is underwritten by Tier One Insurance Company, doing business as Tier One Life Insurance Company in California (Tier One NAIC 92908). o5BD$*Z2jom$PZ&;ZZZSrkbZVqI! Managing your coverage has never been easier. Filing Claims | Aflac Group 21 0 obj endstream #DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! @t8o'GZ4D)sCs51c+#T4\n6>"b>\hV.b\NHH
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Connect whenever you need us. If this is an Employer Sponsored Term Life Product with your policy number beginning with AFL, please use the forms below. [:'^X
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Learn how Aflac pays cash benefits to help with out-of-pocket expenses that your major medical may not cover. a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. Aflac Worldwide Headquarters | Columbus, GA @oGDmsuR-
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Aflac may include American Family Life Assurance Company of Columbus, American Family Life Assurance Company of New York, Continental American Insurance Company (marketed as Aflac Group), Tier One Insurance Company, and any other affiliated companies (collectively, Aflac), as applicable to the entity from whom you receive insurance services. 25 0 obj 3 0 obj Dental and Vision plans are administered by Aflac Benefit Solutions, Inc. ];]KtG'T^mQ6k\65n-CO3CpUj:9mE5T+QAa^Vn$W>6ZWQM=\_oAF,SBqE
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The University is committed to a policy of equal opportunity for all persons and does not discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, or veteran status in employment, educational programs and activities, and admissions. !G5'>m!$kI`%E,=&c9e1!`-(ln6%1Abq7/PK2;m`V,'D51([Fj
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. 'X-2uc/>cM8\5p/T44i`BgV5"LY/5Yg%
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Manage your account, submit and track claims, setup direct deposit and more. You will be automatically redirected in 10 seconds or click the button below to be redirected immediately. If you are filing for disability, please complete the Initial Disability Claim Form (S00224). stream Group policies are offered by Continental American Insurance Company (CAIC). 0000000446 00000 n T9khijaBNZR9C,%t"7Fg@HCRo`)?gN`jH7$+&;F&1h$f-gZ@qpFS8g[qONg*?3muhSPi%q01m@
endobj 0 27 endstream /Type /Font 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. qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib
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endobj endobj No Yes Isdisabilityduetoaninjury? Please provide all the information requested in Part A of the initial claim form. 16 0 obj 'oHV-TGH;:1osTnm1H
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