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INITIAL DISABILITY CLAIM FORM

INITIAL DISABILITY CLAIM FORM Thank you for trusting Aflac with your INITIAL DISABILITY needs. If you are interested in uploading documentation on an existing CLAIM , register using To prevent delays, please provide documentation from your healthcare provider to support this CLAIM . If you have additional bills or medical documentation that relates to this diagnosis other than the documentation defined, please submit them for review of additional benefits. Service related items can be obtained directly from the patient's healthcare provider(s) by requesting a UB04 hospital bill or HCFA 1500 non-hospital bill. Failure to complete all sections may result in a delay in processing this CLAIM .

~ny insurance.company .or other.person files an application for insurance or statement of claim contammg any materially false mformat,on or conceals for !lie purpose of mi~leiiding, jnformation ~oncerning any fact ma\erjal thereto. c.ommits.a fraudulent insurance act, which 1s a crime, and subJects sucli person to criminal and c1vll penalties.

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