Transcription of New Claim Form PDFs for WEB - S00224 - Aflac
{{id}} {{{paragraph}}}
Example: marketing
New Claim Form PDFs for WEB - S00224 - Aflac
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?
*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 …
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: