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?NoYes (If yes, please submit the itemizedhospital bill, UB04, or HCFA 1500) Hospital name: City:State:American Family Life Assurance Company of Columbus ( Aflac )ATTN: Claims Department 1932 Wynnton Road Columbus, GA31999 For information or to check claimstatus, visit call 1-800-99- Aflac (1-800-992-3522)Claims may be faxed to 1-877-44- Aflac (1-877-442-3522) S00224 CTPage 1 of 302/14*Sex:MaleFemale*Relationship:Prima ry PolicyholderSpouseAny person who knowingly and with intent to defraud any insurance company or other person files anapplication for insurance or statement of claimcontaining any materially false information or conceals forthe purpose of misleading, information concerning any fact material thereto, commits a fraudulentinsur
*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 …
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