Transcription of New Claim Form PDFs for WEB - S00224 - Aflac
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New Claim Form PDFs for WEB - S00224 - Aflac
DUCKP olicyholder Information:This * denotes a required field.*Policy Number:////------Patient Information:////Initial Disability ChecklistIs disability due to a sickness?NoYesIs disability due to an injury?NoYes If yes, please complete the following questions related to the injury: Date of the injury:// Describe how the injury occurred: Was this disability caused by an incident that occurred while performing the duties of the patient s employment?NoYes Was this a motor vehicle accident in which the patient was the driver?NoYes (If yes, please submit a copy of thePolice Report) For all claims, please complete all remaining sections. Was the patient confined to the hospital as a result of this condition?
Title: New Claim Form PDFs for WEB - S00224 Author: Registered to: AFLAC Created Date: 4/10/2014 14:39:54
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