Continuing Disability Claim Form
ADVERTISEMENT
1
2CONTINUING DISABILITY CLAIM FORM
Failure to complete this form in its entirety may result in a delay in processing this claim.
FILING CLAIM FOR:
Disability due to an Accident
Disability due to a Sickness
Disability due to Pregnancy / Complications
Disability due to Cancer
Accident
Short-Term Disability
Policy Number
Policy Number
INSTRUCTIONS:
♦
Complete Section A: Policyholder/Patient Information.
♦
Your doctor should complete and sign Section B: Physician's Disability Statement.
♦
Your employer should complete and sign Section C: Employer's Disability Statement.
♦
Be sure to sign your claim form at the bottom of Page 1.
SECTION A: POLICYHOLDER/PATIENT INFORMATION
POLICYHOLDER'S INFORMATION
LAST
FIRST
INITIAL
SOCIAL SECURITY NUMBER (optional)
BIRTHDATE
PHONE NUMBER
(
)
ADDRESS
CHECK BOX IF THIS IS A NEW PERMANENT ADDRESS }
CITY
STATE
ZIP
PLACE OF EMPLOYMENT:
PHONE NUMBER
(
)
ADDRESS
CITY
STATE
ZIP
PATIENT'S INFORMATION
LAST
FIRST
INITIAL
SOCIAL SECURITY NUMBER (optional)
BIRTHDATE
RELATIONSHIP:
SELF
SPOUSE
DEPENDANT -- CHECK IF CHILD IS FULL-TIME STUDENT
MALE
FEMALE
SINGLE
MARRIED
OTHER
Date of incident: _____/_____/_____
Describe where and how the incident occurred:_____________________________________________________
________________________________________________________________________________
For your protection California law requires the following to appear on this form: Any person who knowingly
presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
_________________________
_________________________
______________
CLAIMANT SIGNATURE
FAMILY RELATIONSHIP, IF NOT POLICYHOLDER
DATE
American Family Life Assurance Company of Columbus (Aflac)
Attention: Claims Department
Worldwide Headquarters: 1932 Wynnton Road, Columbus, GA 31999
For information or help filing your claim, please call toll-free 1-800-99-Aflac (1-800-992-3522) or visit our Web site at
Toll-free fax number 1-877-44-Aflac (1-877-442-3522)
S13270CA
04/05
Page 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal