INITIAL DISABILITY CLAIM FORM

1 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 . Disclaimer: Some of the services listed may not be covered by your policy. *Policy Number: J I I I I I I I I Policyholder Information: This * denotes a required field.

2 "Last Name Suffix "First Name Ml 111111 11111111111 DJ 111111111111 "Date of Birth (mm/dd/yy) Telephone Number where we can reach~ I I I I I I I I I I I I I 1-1 I I 1-1 I I I I "Home Address I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I city "State "Zip Code I I I I I I I I I I I I I I I I I I I I DJ l,--'-,,-1 ~I ~I 1~1-~I 1~1 ~I I D Check box if this is permanent address change. Patient Information: "Last Name "First Name "Date of Birth {mm/dd/yy) I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 'Sex: 0 Male D Female 'Relationship: D Primary Policyholder D Spouse I INITIAL DISABILITY Checklist Is DISABILITY due to a sickness? D No D Yes Is DISABILITY due to an injury? D No D Yes 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?}

3 D No D Yes Was this a motor vehicle accident in which the patient was the driver? D No D Yes (If yes, please submit a copy of the Police Report) For all claims, please complete all remaining sections. Was the patient confined to the hospital as a result of this condition? D No D Yes (If yes, please submit the itemized hospital bill, UB04, or HCFA 1500) Hospital name:----------------------------------- City: _____ State: _____ _ Any person wh9 knowingly and with intent t9 defrau<! ~ny .or 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. fraudulent insurance act, which 1s a crime, and subJects sucli person to criminal and c1vll penalties. POLICYHOLDER/PATIENT SIGNATURE family RELATIONSHIP, IF NOT POLICYHOLDER DATE S00224 american family life assurance company of Columbus ( aflac ) ATTN: Claims Department 1932 Wynnton Road Columbus, GA 31999 For lnfomiaUon or to check clatm status, visit or call 1-800-99- aflac (1-800-992-3522) Claims may be faxed to 1-877-44- aflac (1-877-4-42-3522) Pa90 1 orJ 02/14 INITIAL DISABILITY CLAIM FORM -EMPLOYER'S STATEMENT *Policy Number: I I I I I I I I I Policyholder Information: This * denotes a required field.

4 "Last Name Suffix *Flrst Name Ml 111111111111111 I I I [D 111111111111 "Date of Birth (mm/dd/yy) I I I, I I I, I I I "Employee's Name (Last Name, Suffix, First Name, Ml) I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I Employer's Nam6"Account # Employer's Phone Number I I I I I I I I I I I I I I I I I I I I I I I I I 1-1 I I 1-I I I I Employer s Address I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I c1ty state _ 2= '-od'-' ----------111111111111111111111 [D 111111-1111 First date of DISABILITY : ___ ,.._ __ ,.._ __ Was this DISABILITY caused by an incident that occurred while performing the duties of his/her employment? D No D Yes Prior to this DISABILITY , number of hours worked per week: _____ _ Gross annual income prior to DISABILITY : _____ *Income is subject to verification at time of CLAIM .]]

5 Self-employed? D No D Yes (If yes, your gross annual income is the average of your net earnings for the past two years. Please submit tax records for the past two years.) Has the employee returned to work? D No D Yes If no, expected return to work date:---~--~--If yes, date returned to work:--'----'----If the employee has returned to work is he or she working: D Full-Time D Part-Time D Light Duty If working part time or light duty, please provide the number of working hours per week: _____ _ If part-time/light duty, date expected to return to work to full-time: __ ,.._ __ ,.._ __ If part-time/light duty, is/was the employee earning at least 80% of his/her pre- DISABILITY salary? D No D Yes Please complete this section only for W-2 Employees and/or Contract 1099. (Please contact payroll and/or check the policyholder's Salary Redirection Agreement/Premium Deduction Authorization card for the answer to these questions.)

6 Are DISABILITY Rider or Short-Term DISABILITY premiums deducted from the policyholder's paycheck on a pre-tax basis? Does the employer pay a portion of the DISABILITY premium for the policyholder? D No D Yes (If yes, what percent? _____ %) Policyholder is: (Check all that apply.) D Exempt from Social Security D Exempt from Medicare D Subject to RRTA Date of hire: ___ _,_ __ _,_ __ Is the person still employed? D No D Yes If no, last dale of employment:---~--~--Please note: The employer is required lo report DISABILITY benefils paid on pre-tax plans on Form 941 and the employee's Form W-2. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of CLAIM containing any materially false information or conceals for tlie purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and subjects sucfi person to criminal and civil penalties.

7 EMPLOYER'S SIGNATURE EMPLOYER'S PRINTED NAME TITLE DIRECT PHONE NUMBER S0022-4 american family life assurance company of Columbus ( aflac ) ATTN: Claims Department 1932 Wynnlon Road Columbus, GA 31999 For infonnatlon or to check CLAIM status, visit or call 1-800-99- aflac (1-800-992-3522) Claims may be faxed to 1-877-44- aflac (1-877-442-3522) Page2of3 DATE 02/14 INITIAL DISABILITY CLAIM FORM -PHYSICIAN'S STATEMENT *Policy Number: I I I I I I I I I Policyholder Information: This* denotes a required field. Last Name Suffix "First Name Ml 111111111111111 I I I DJ 111111111111 oate of Birth (mm/dd/yy) I I I, I I I, I I I Patient Information: Last Name First Name oate of Birth (mm/dd/yy) I I I I I I I I I I I I I I I I I I I I I I I I I I I I I' I I I' I I I Physician Information: "Phone Number Fax Number I I I 1-1 I-I I -I I I I I "Physician's Name I I I I I I I I I I I I I I I I I I I I I "Address I I I I I I I I I I I I I I I I I I I I I "City I I I I I I I State Zip Code DJ 1=1.

8 :;.._1 ~11~1-~l l~l~I I Primary diag osis for DISABILITY and ICD co e: _____ Additional diagnoses: _____ _ If due to an injury, please provide the date and details of the injury: / / Was this DISABILITY caused by an incident that occurred while performing the duties of his/her employment? D No 0 Yes Symptoms first occurred on:--~--~--lf diagnosed with cancer, date of INITIAL diagnosis: Patient first consulted you for this condition on: _ _, __ _,_ __ _ Was the patient treated for the primary diagnosis by another physician? D No D Yes If yes, physician's name:-------------------------------Trea ting physician's address: _____ Phone Number: _____ _ *If filing for DISABILITY within the first two years of the policy, medical records may be requested. Pregnancy claims: Date of delivery: Vaginal D Cesarean If not delivered, expected delivery date: ---~-~---Please advise of any complications: _____ _ First date of DISABILITY : --~--~---Date patient was last treated: -~--~---Have you released the patient to return to work?

9 D No D Yes (Date released: __ _, __ _,_ __ _ Patient released to work: D Full Time D Part Time D Light Duty If part time/light duty, please provide the date the patient is expected to return to full duty: _____ _ If patient has not been released, please provide the next appointment date: ___ ,__~c_ __ Please also provide the date of expected release: --~-~---Is patient permanently disabled? D No D Yes (Medical records will be required if permanent DISABILITY is indicated; please provide medical records to patient.) Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of CLAIM containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and subjects sucti person to criminal and civil penalties.)

10 PHYSICIAN'S SIGNATURE DATE TAXID S0022,1 american family Lifo assurance company of Columbus ( aflac ) ATTN: Clalms Department 1032 Wynnlon Road Columbus, GA 31999 For lnfonnalion or lo check CLAIM status, visit or call 1-800-99- aflac (1-800-992-3522) Claims may be faxed lo 1-877-44- aflac (1-877-442-3522) PagoJolJ 02114