Transcription of New Claim Form PDFs for WEB - S2029 - Aflac
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New Claim Form PDFs for WEB - S2029 - Aflac
Policyholder Information:This * denotes a required field.*Policy Number://---Patient Information:*Last NameSuffix*First NameMI*Date of Birth (mm/dd/yy)Telephone Number where we can reach you*Home Address*City*State*Zip Code*Last Name*First Name*Date of Birth (mm/dd/yy)//*Sex:MaleFemale*Relationship :Primary PolicyholderSpouseDependent ChildCheck box if this is a permanent address Indemnity Checklist*If filing for a claimwithin the first two years of the policy, medical records may be requested for evidence treatment due to an injury?NoYesIf 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.)
Title: New Claim Form PDFs for WEB - S2029 Author: Registered to: AFLAC Created Date: 8/10/2021 01:21:38
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