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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. ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR 0000001422 00000 n endobj In New York, coverage underwritten by American Family Life Assurance Company of New York. 0000049332 00000 n rT)4FF1EPoVMN14>L,`\V:)bIb1npmugX^4,7NbhZ&&T,/8(>f=lM4?OnHSHRdi endstream "k&*mXEOTDY; /Subtype /Type1 endstream Claims are subject to policy terms and conditions. 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DCl*mJUg=pq^:YnVX2rH-?MoX;V+!pDt12?)+Ag/%cNZV^V$#m+E*A#TQr? 0000054442 00000 n endobj m);lB2NZG/rMHahB@? 2@Aq[=+(TD3oRc#`>K/0ZNjU%/:30? 0000001020 00000 n IsNhEk,PeVb^BZe[*I4rabcN&lDZ'ULHK+-T$;u]WD3GH('p*58J'[(3mgr(:*0TR2iG4M503dao>uU! Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). Execute Aflac Initial Disability Claim Forms To Print within a few minutes following the guidelines below: Choose the template you need in the collection of legal forms. If you have already had your physician complete and return this form, simply select "File Online" below and follow the instructions. State-paid family leave View more Life insurance View more Long-term disability insurance View more Short-term disability insurance View more Leave of absence View more Contact us endstream 15 0 obj ?5QKLuXe>d/Imj *-ogCe2UsEgf\'ds_/jiZfh5I(c[]]fP=H[DUhhQ4'/;X2hk?KsbO!`rDQ2eS&bFI1P0&@J-^!k9`KO(igH\q^TX%?G:9) c)$el$_7T'R>`H4d?VZZ.6:FXa^5[8hKt_jJ5`+n^Hma14HF`L'+tk,U=9slnfp8]Z?2MS[;()=`R endstream GgU]JcO2rI@MJ!M*4mh6R`a.PLnCe-ET<>a;*-c;Tf1f endobj In NY both group and individual coverage is offered by American Family Life Assurance Company of New York. 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[:'^X 26 0 obj Fill out Aflac Continuing Disability Form 2019 in several minutes by following the guidelines below: Select the template you need from our library of legal forms. 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY ;dps@dXdX$3sN65dLrqK;34,XZ>#G6k1;= )S.%6`+GjIZj](Q#<=c@2$Z7dM/>T[*ou6=\86%`.6Tf9_%C^ECG2N>a#UsXf8l(9b*mV6r!V.s)b^~> 21 0 obj 7.XdOm?gqE4o-8r9 stream Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r !o5ERV47$k+S(!Xa"PN!I9]Y4"VHDRe8O[\PP>C\n_[q%@(=l5'/%#n49 Get more info about Aflac for business owners.. Aflac promised to be here when you need us most and a big part of that promise is making the claims process easy. 8e==QcdnYk8&(`lkD;,]b;+SbfrO-.*]B,RLFCV[]Pa\Z? 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Gl[`Vs#gklP69lm%%T22\kX&">D8=oK\TZW)P!IRM1g^=+9\uBMam13]#$n%@WS1?.N5'V*UaY%l0"YM ;Y'TZ`#NiWQ ::bl''..9BC;a\$BlT\:t-X,fsW*QN`2e(KL jd*ZcXe"_QS4SaSM0H8\:kGm7EGchf:.,NK]?.0?7FYh&?aae5>4\THpn]0*9A8N "DFX!Fen1$B29'W4#sWKq 0000000446 00000 n *Jn&hZmHE?Eu$9%^_jrU\Fh>uH`k,8rK Enter all required information in the necessary fillable fields. Aflac Group | Columbia, SC ^D"tO6srOZFP9$! [u"0oO\5'j_^6BobJWi[hgme'ak6Kf@+ 01Kfu^/nVO+L(Jdq73kWrp8S-B^0`qh,U[o.OS(9*S//rm]sB[#0$Ikq. startxref :JP2npQHaeod^X7'sK!^CIY561O?2S)MJ3_5]Y=4,Cn7b%K5Me(p[?9MOo\lj=] >> ["`,abhS3LE"C=T6]&k%"Zl4BdN^JG3F!Y*CQe"Xqj- 0000035380 00000 n 6 0 obj a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. Q[WGEfLmSJlD4aAIQg]>]O"6oFV!6AQ*&I%W1?E?iS+o&0c^Yc&U1]$I6mp;f=sCk)`?#3^FVJTgJrGe_1^q4-mOnYK@c1T5eKoO`M^;`6u-:]MC=Xh]*G+XUYfH(M?5 >> U;s(7Es'Hq&:@a]^0oUGCJa3R7thK`//"XdS%5f,bl:[\>V0EGJX9:R[P$&(L2fO4E"!r*bnZA.0JbrSKY5@2H. Claimsmaybefaxedto1-877-44-AFLAC(1-877-442-3522) NY-S00224NY Page2of3 02/14 *LastName Suffix *FirstName MI *DateofBirth(mm/dd/yy) *Employee'sName(LastName,Suffix,FirstName,MI) *Employer'sName/Account# *Employer'sPhoneNumber INITIALDISABILITYCLAIMFORM-EMPLOYER'SSTATEMENT EMPLOYER'SSIGNATURE EMPLOYER'SPRINTEDNAME TITLE DIRECTPHONENUMBER DATE nhH(@HB3(k..$A&2I&hNumCF[&]PjI*`R_D2M6]X>#-E#f;915&(PF6%>9Knd"E.:PO Health care provider includes . ;]2"WH3RN-IY-eA348fl;R6]T4%O*^emkHfI8Di4T'&!Ns\94;%b (V.ea8oM1meVG5&2$R&VHdRmbM`,/jQ'iTTlk_NLi7Pu8>hqB>F6,at#]$=1\UL'_o 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). I:V.I`2dr"RI-usXpWjkY@>M8)rABTHrdsdGSrnt>bM>*rdMgSo-0,QN0AdB$2JDlipKX1lo%-6ppko&)?kL6M8p"kK6P^Jj+s;af.%X>Efh47/[PqC. endobj endobj ?5QKLuXe>d/Imj endobj trailer<> Please provide a certified copy of the deceased person's birth certificate and death certificate. 3. Download the data file or print out your PDF version. N)G#g,5CuOCl3ttm>moVq5\t:irQ`YOX`hI[-7k@LAI*:FcS$CfJQIJO'l@aSJln)/KXYQh;4`]9N;Qj o5BD$*Z2jom$PZ&;ZZZSrkbZVqI! 14 0 obj ,-TQAaYC[5-ru"XbG^9qf`7Q_V*TD8eW0!d4tTL2](RU^lH!V+k6L3^9)d)_:\E 0000054815 00000 n <> Please provide all information requested on the Insured's Statement portion of the claim form. )S.%6`+GjIZj](Q#<=c@2$Z7dM/>T[*ou6=\86%`.6Tf9_%C^ECG2N>a#UsXf8l(9b*mV6r!V.s)b^~> Then, follow the simple steps below to begin the claim process. To file a life insurance, disability insurance, or absence claim, click the button below to access the member portal. A BenExtend claim requires supporting documentation for review of benefits such as an itemized bill if there was a hospital stay, itemized bill from physician's office, surgical report if surgery took place, Xray/Diagnostic Test reports with dates and charges if applicable, accident report if applicable, and a signed and dated Authorization for Disclosure of Health Information (HIPAA form). <> endobj <> c5lMh,QXUsVpDOgY[E488MHV?GK9DUk^qXiSo6?d"#T=f:;YTi0SU1_S\M2I.26bpPB\Xsl"fN>oQoH- "kt65Ko1TNq1+;X4?fH1W0SbI2D-F(6cs2(!E?1oM!HZ/`bJ.Cb4@4gWrBVNX,G01o;?NA0^%)?aS>EJ <> >> 2#Uk88j6F;!LPJCYg?_VnT>DO7>((M$tI28>B]"L9/3#3R1],d$6!$JJRKV2m(tG_Q]-T()Va>`2T]>l;eK>s(U,g-lu^? endobj ?/8-TEfAU,j[:b-G[DjC57H"+$-Ag(@hZ fKM7f%?5*K:i'+aV_K!?49DLRD(oBT]NI)%kf!BU%-f'rI-kJBX(Gn\B]/9qU,\iQ;,gU.Z@%@^>"[]W:T%89f)q@tlS'SN77! 0;p5g%:Gd\>Io0dB\q^f8G>h/i$&$eAg8lGgN!bHFN/%]=BXD&^?mb,/u7t)rbDTL)pZ8Q"RdB*(8=i? 2@Aq[=+(TD3oRc#`>K/0ZNjU%/:30? .mN(97.aR@?hUC/hmO_H@-r$8(#H,d[mojB7?G" <>stream 32h0$$08-8TYS-cMZH4Z@mV"tA/C(INdbs#Y3A\%VXCNMeOT)V?mHH\@]`s8D$dlP#B>-]=L]c3bUZ5nds%jlGpH>? _^7`jFRJiik^>[sr;K_R=oP`RhjIDn7[PIg5,_,"obk"U42[,7b`:kTqB'Do)liYcA9l:=H+qjE). 3TjKSEQ8:S+XUe3iJa"79`?s5c,-YU]aQt>=/Q\K4ePWk8tUHMNos%)gp)1M'YH]uh'HQ!l(m'P9e66@:#UA1$A@flpm 0;p5g%:Gd\>Io0dB\q^f8G>h/i$&$eAg8lGgN!bHFN/%]=BXD&^?mb,/u7t)rbDTL)pZ8Q"RdB*(8=i? 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Life claim forms for the state of Illinois must be obtained by contacting Aflac Worldwide Headquarters at 800.992.3522 to have the appropriate forms sent to you. 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. AkJD?1M>up>BcsX+I=_#LC$k%qGLcEUfd4i%!i& Have questions? 0000054815 00000 n "iE5=j8``/gXCMXF Select the Get form button to open the document and move to editing. 16 0 obj <>stream endstream 19 0 obj 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/ai^g,u(4jLe=m[4V59--p2Tap(*UC^8Qur;jVC%5c7VaBB+,0AUKH@dUPF5MD 18 0 obj 0000035380 00000 n Simply click Done to save the adjustments. Z'qla+"Ni'F7cdihoHcj(u=..e%DbtGJWZF/nB*]I!`;q;hE9aN=iqM2-6r0A.0!kYlX,(D DE.V"?h'jom'g4taZ=ggb[Rq9*%"D3_?>DBHcG"%EYhs\A)[02C%,[#:eC])1_\$c?cV\_3\d).P:QmEm*p#YH<04bhGCYr_BRigd-lMFY&qm3!U7+E'.29BdD[1$Xoi)[=&jM/3ntoZ9Yk9SnM:+ Please include all dates of treatment and charges incurred due to the accident. "iE5=j8``/gXCMXF jPHFW8nlme]HU. "Jk(XbKsV#$D'i]&;mcIV!r IsNhEk,PeVb^BZe[*I4rabcN&lDZ'ULHK+-T$;u]WD3GH('p*58J'[(3mgr(:*0TR2iG4M503dao>uU! IulVik4tYO+5Y]5dC6+if#]pW>?S#%PB"2$kEPR@U_!W)J++r5@@21spCE@V_m\2SM=jcqaH.-P9&U%f 3mQ%,1)gj;9$&S!\%GgUIJtYQ=_8pbJK)n9=AhVBAWh/*_5LS#%,`3%e$TMO+0\q]13BVh1cl87bY77Q 34KC`g@bObJ6!O^[4KaLHd&d3Z>1B[8K]!Ma[U/7j$GS6:@5eWk>jl+X?+>PG9h*%gY?g&"\0cQnsu>;4$NAR_h9iPdY^EdXqEH&r&?URsH:@b+fJ3ul5P0*OfoJU+qB&mF'>3T)PgN9! >/FRGOB+OB[1iVR22-7Lnt@)K1T_gY[7;kiM;`1C&61:AoC42ST7*!-T+uZ3:t]s'Eh(_u3^02+HBBV<
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