New Claim Form PDFs for WEB - CW06199 - Aflac

1 Accident/Hospital Indemnity Wellness Benefit ClaimFormTo file your claimonline, register on download the MyAflac mobile app. Benefits of filing your claimonline include faster claimprocessing time and receiving claimcommunications by read all instructions and complete the form , failure to do so could delay the processing of your check your policy for specific details on this benefit. Do not include receipts, statements or other claimdocumentation with this form . Do not write on formexcept as instructed. Sign, date and fax or mail the completed formto the Aflac fax number/address shown below.

2 Use black or blue ink only and print legibly when completing this formin its entirety. Mark only wellness examboxes for test(s) and/or treatment(s) received. Failure to complete all sections may result in a delay in processing this Claim . Some types of tests and/or treatment listed may not be covered by your keep a copy of this completed formfor your records. Please print a separate formfor each additional familymember or call 1-800-99- Aflac (1-800-992-3522) to request additional forms. Claims for all other benefits coveredunder this policy must be filed separately using the claimforms available at by calling 1-800-99- Aflac (1-800-992-3522).

3 DUCKA merican 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)CW 061999 FLPage 1 of 202/14 Policyholder Information:Policy Number:Patient Information:Last NameSuffixFirst NameMIDate of Birth (mm/dd/yy)Telephone Number where we can reach youHome AddressCityStateZip CodeLast NameFirst NameDate of Birth (mm/dd/yy)POLICYHOLDER/PATIENT SIGNATUREFAMILY RELATIONSHIP, IF NOT POLICYHOLDERDATEP hysician's Street AddressPhysician's CityState:Zip:Physician's NamePhysician'sPhoneNumber:Check box if this is permanent address Fields are PhysicalUltrasoundPSA (blood test for prostate cancer)Pap SmearBlood ScreeningImmunizationsEye ExamDental ExamSex.

4 MaleFemaleRelationship:Primary PolicyholderSpouseDependent ChildMMDDYYYYA merican 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)CW 061999 FLPage 2 of 202/14 Accident/Hospital Indemnity Wellness Benefit ClaimFormTreatment and Physician InformationMammogramFlexible Sigmoidoscopy/--///--Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement ofclaimor an application containing any false, incomplete, or misleading information is guilty of a felony ofthe third Provider listed above is authorized to validate the information I have provided.