0000043507 00000 n 0000000009 00000 n (8p@RL@:%uhr=mo1Fg6rg/M;<4* )_uYFAPMnh@@qLR(!tj0,JgDV:^2aU1j,Q1G5%+A&.^pn]C"PJA:oAllMYj0psPAVZ_E,8iGS^\I&;A'/E"CXIR`WpK_.^,?uB7C2c/q!Ft;r%bq\)j#XX/c~> 23 0 obj 1 0 obj 14 0 obj In NY both group and individual coverage is offered by American Family Life Assurance Company of New York. 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Yku1YRdk^9;TD\;*kl4jYjTa8Xl"SC:fUS)e;!AcrDK#l16`LFaGhEJ;`,G>'H*8^Jr\^>/E?FZ]1S?b 0000043584 00000 n A(lCW]h%VdMt:8Y)JTJc(@p\,K2F73Vt)lr]_VGs^b4MoT7ZmT:ZlP&6C?-PWabHK;JrCnJnrcc Then, follow the simple steps below to begin the claim process. 0000030858 00000 n 0000054815 00000 n If you were first treated in an emergency room, a copy of the hospital discharge papers is required to verify the first date of treatment, diagnosis, and procedure. m^PaP#$T,QfVQ'7kTb=#ja*O^[oT:q1qW?WH%a_Lp. endobj 0000054519 00000 n m^PaP#$T,QfVQ'7kTb=#ja*O^[oT:q1qW?WH%a_Lp. 46a&g>*Zg/Di4fH;%L. Aflac Short Term Disability To sign an flag initial disability form right from your iPhone or iPad, just follow these brief guidelines: Install the signNow application on your iOS device. File a Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claim, File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company Claim, File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company, Do Not Sell or Share My Personal Information. /Encoding 4 0 R 3TjKSEQ8:S+XUe3iJa"79`?s5c,-YU]aQt>=/Q\K4ePWk8tUHMNos%)gp)1M'YH]uh'HQ!l(m'P9e66@:#UA1$A@flpm 0 27 "Jk(XbKsV#$D'i]&;mcIV!r eiE#q%9eO%886=-()4_+S4PR>Y.OpD>thDms)r(iY76&nF\4eSBh"@D8Ckg?OT/fVbq-a!hKg2P8WFKC*e*%O1YLY&R&=h#U$ endobj ?5QKLuXe>d/Imj 18 0 obj $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR ;Y'TZ`#NiWQ Learn how Aflac pays cash benefits to help with out-of-pocket expenses that your major medical may not cover. V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT !G5'>m!$kI`%E,=&c9e1!`-(ln6%1Abq7/PK2;m`V,'D51([Fj [lXipns%dYmtWgT45TNAg1!L7&LsF1AVS8,9_:a+p=0JYXs63uqK)DZMF:+=COnscG]5l!0l_(jD#HTn3T/Nq3TXul_X>mcZ"L&H2kUp].^k.4,_Aof>Ug=,=b3fQf+d*!6h*m;*04i'C0/[p+\Sgs.&*IjrlVLg~> 7.XdOm?gqE4o-8r9 /2R!i5j&PBRjtAnemGT^T>r)/aH+##c99WL>k&k>=:> 3TjKSEQ8:S+XUe3iJa"79`?s5c,-YU]aQt>=/Q\K4ePWk8tUHMNos%)gp)1M'YH]uh'HQ!l(m'P9e66@:#UA1$A@flpm Once completed you can sign your fillable form or send for signing. Claims are subject to policy terms and conditions. 0000049255 00000 n ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; <> @lR;bed"/KM4=.N)6,FfJ&AfVrJm-US A&!R^maAJpBZW3)>! endobj 0000000000 65535 f endstream Please fully complete the claim form for the Wellness Benefit. 0000000686 00000 n 0000040092 00000 n !$"P3qfbXDLeQ[oZ1B!OZ7r(l@ 0000000326 00000 n 6,k1;gaBDk.XY%J:F9As.#C&J>pqd^X_`2(g"7EVNm@*ELI1%cI *PolicyNumber: / / - --Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementof ,-TQAaYC[5-ru"XbG^9qf`7Q_V*TD8eW0!d4tTL2](RU^lH!V+k6L3^9)d)_:\E 0000054923 00000 n <> !G5'>m!$kI`%E,=&c9e1!`-(ln6%1Abq7/PK2;m`V,'D51([Fj 0000000009 00000 n :0&HC(d$*r1.Y<=jD`$Ia7bVR3*X"Pd8ODQ(-pM4B8oHgR /Subtype /Type1 stream Log in to to your account or Chat with us. Enter all required information in the necessary fillable fields. qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib @$)Lh&6Egt'qa=4JCbEhf.D@]'4gOBhAJ\j-2@i1Of6HUn&0Zg!2[-CMUcDL,99I`W(Mo=4ulk";_tepAHfJ;F[K'*>:ebQ]rrd/^N-lJT7#)95uN-MWu5OG R5BsS,N[X$9*1Su`V5!FLu53L/`5$Sl[7rqO,!^]g&GFP&S?ljI>6jN,bnDr8aF$lN\@CTOcGe"W!E$o If this is a Disability Product with your policy number beginning with AFL, please use the form below. 2@Aq[=+(TD3oRc#`>K/0ZNjU%/:30? <> :JP2npQHaeod^X7'sK!^CIY561O?2S)MJ3_5]Y=4,Cn7b%K5Me(p[?9MOo\lj=] endobj U;s(7Es'Hq&:@a]^0oUGCJa3R7thK`//"XdS%5f,bl:[\>V0EGJX9:R[P$&(L2fO4E"!r*bnZA.0JbrSKY5@2H. h/#o:*lSpdqlZg*XqFsNY5T/YFk%>_'?0&0X0BaP:*/_(BP1Z\9IQQ3"3LWkO02ijH;rAcRPahK(DRaJ Online Claim Form Aflac https://www.aflac.com/file-a-claim/default.aspx When you use MyAflac filing your claim online is an easy way to get paid fast. 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Aflac Continuing Short Term Disability Claim Form Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf Please note: The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee's Form W-2. "\1ceiPob[!+@J3(3TJ)YX)OUj[W9&;I:dYZ=kc)4eebY'g`kA>>[&O][obn/UEdfgRXrat28;.HM:HQa#NGoYVo#="o%! 0000000563 00000 n View Site Aflac Initial Disability Claim Form Capital Insurance Agency Aflac Initial Disability Claim Form <>stream Your dentist should complete the Billing Dentist section, Boxes 4266 (excluding Box 53). For critical illness claims, we need information from you and your attending physician. Aflacs Premium Life, Absence and Disability Services are available in all states, except Puerto Rico, Guam or the Virgin Islands, and are offered by Continental American Insurance Company (CAIC). endobj <> <> Yku1YRdk^9;TD\;*kl4jYjTa8Xl"SC:fUS)e;!AcrDK#l16`LFaGhEJ;`,G>'H*8^Jr\^>/E?FZ]1S?b Rf;iu7gGe[$chW^;W6Fl=BqZ%6KIFZ'HNb5)TaYYGG:'$r`) @t8o'GZ4D)sCs51c+#T4\n6>"b>\hV.b\NHH >> "D=hF9Hc;3b+uU#87#u->Oo&ZR/kmg`A@Va9ssE1`$L205UY2\m1KJ?'g1*p?gL[/Z6a.dV! endobj File a Disability Claim File a Hospital Claim File a Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claim File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company Claim Aflac Group Insurance Additional Forms Authorization to Obtain Information Form Direct Deposit of Claims Payment Form 0000000446 00000 n Click the Get form key to open it and start editing. For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York. 44EBCGZWK1$09&Q#o?-4-.oof+30H,2'QUFu;$7Pkc ="8)^bHRPR0S#pBp\Hna_9-7K:diCtrB)_+K-\[email protected]=Up^98J,Q-AtX6'$lc%D"gK+_Uc1u""HolR4)Hdg&NuR#8)Khmcol]#;]R+7)60eW.q/;.KZ6p49FV Please provide a date and complete description of your accident. To file a life insurance, disability insurance, or absence claim, click the button below to access the member portal. 0000049332 00000 n GtHt%Nh;7F1(!K[n[8/1g\PTUNaGT"=n\Bb:62T:Xt#[Q]!mJ,M&0#sD9($J$JR;eXA\0%6Xp-RXgTNJt5f^? 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