Form 1099 Workers Information Sheet


The following information, to be completed and signed by a company officer, will allow Aflac to
consider your request to offer coverage to 1099 workers:
Company name: ________________________________________________________________________
Address: __________________________ City: ________________ State: ______ ZIP: ____________
: _____________
This account is New
If existing, please provide the account number
Is this a Multi-Location Account? Yes
Total Number of Employees (to include W-2 employees and 1099 workers):________________________
Number of 1099 workers:________ (Count 1099 owners as W-2) Number of W-2 employees: ________
1. Does the company issue a Form 1099 to the 1099 workers? Yes
2. Do the 1099 workers receive wages\earnings\compensation from the company? Yes
If yes, are you willing to deduct the Aflac premiums from the 1099 workers’
wages\earnings\compensation? Yes
3. Will you allow the same enrollment conditions for the 1099 workers that you allow for the W-2
employees? Yes
Company officer name and title:____________________________________________________________
Associate name (please print): _________________________________ Writing number: ___________
Fax number: ____________________________ Aflac E-mail address only: ______________________
Please note:
For this exception to be considered, the business must employ both W-2 and 1099 workers and meet the requirements for
establishing an Aflac payroll account (i.e., a minimum of three W-2 employees participating in the Aflac product offering).
Owners that receive a 1099 are considered employees for purposes of obtaining 3 W-2 employees.
The cancer, base accident (no riders), hospital indemnity, life, dental, and hospital intensive care policies are available for
payroll rates on approved 1099 workers.
Short-term disability, group term life, long- term care and the disability riders cannot be offered to the 1099 workers.
Coverage on all Form 1099 workers must be written on an after-tax basis.
It will be necessary to establish two accounts: a master account for the Form W-2 employees and a sub-account for the
Form 1099 workers. All coverage for the Form 1099 workers must be written on the sub-account for the Form 1099
If approved, a complete listing of the company’s employees, as well as a listing of the individuals who receive a Form
1099, must be faxed to New Accounts at (866) 235-6272 along with a copy of the approval letter prior to submitting
Fax form to: Sales Support & Administration, 800-849-2943
American Family Life Assurance Company of Columbus, Georgia (Aflac)
Worldwide Headquarters: 1932 Wynnton Road, Columbus, Georgia 31999


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