Aflac Short Term Disability Claim Form. Date of birth gender policy holder’s address: Web form a57601coh 1 of 9 a576c01coh.2.
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Web form a57601coh 1 of 9 a576c01coh.2. If this is a disability product with your policy number beginning with afl, please use the form below. Policyholder’s statement (forms are to be completed on or after disability date to avoid processing delays) Short term disability/long term disability claim form Policyholder’s statement (forms are to be completed on or after disability date to avoid processing delays) Please sign and return the attached hipaa. Web for claim forms, visit our web site at aflac.com. This * denotes a required field. Web short term disability claim form. My coverage here you’ll find a copy of your policy and benefit details to see what’s covered and benefit amounts.
To avoid delay, all questions must be answered.) please complete both pages of this form for pregnancy disability only: Web notice of claim for short term disability benefits long term disability benefits employee’s statement (to be completed by employee. That means no medical questionnaire is required. Web short term disability claim form *please attach paperwork for any additional income you are receiving during this period of disability.* **please sign and return the attached authorization. • it’s sold on an individual basis. Nt (forms are to be completed on or after disability date to avoid processing delays) policy holder’s name: Web for assistance or information, call 1.800.99.aflac (1.800.992.3522). *last name *first name *date of birth (mm/dd/yy) / / physician information: Include tax records, at the time of claim. *last name *first name *date of birth (mm/dd/yy) / / physician information: This is a supplement to health insurance.
