)lM~> <> 0000054624 00000 n CAIC is not licensed to solicit business in New York, Guam, Puerto Rico or the Virgin Islands. Managing your coverage has never been easier. ;PmE,29/@]Q_gjie3>F*fbNG$7H6^5^trSgt@MX18^JE+B$K
Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). 2#Uk88j6F;!LPJCYg?_VnT>DO7>((M$tI28>B]"L9/3#3R1],d$6!$JJRKV2m(tG_Q]-T()Va>`2T]>l;eK>s(U,g-lu^? 02rhl21qBSA"(T]mcU-(M+$l6hA!\lUur6,-iT#]. /BaseFont /Helvetica-Bold startxref #DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! 2 0 obj 0000054815 00000 n endobj QQZnEET3`^=L@5Inq5fkUd?/3Y2`;02=IqDob^'R&m,FG.6*VIW,-bt2>#UYOZJj>;fU1^9uM()U8*1b
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Manage your account, submit and track claims, setup direct deposit and more. 7.XdOm?gqE4o-8r9
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Send it in to: PO Box 60676, Worcester, MA 01606, Long Term Care/Home Health Care Benefit Claim Form, Automatic Bank Draft/Electronic Funds Transfer, New York Domestic Violence Notice (For Life Insurance Policyholders). Gb"/l>AkOk&]_Z/^,64CCgQh(QQim(`'@6(M1VCS?Ymokm)Y?"923o3hrP9g4Yu*CcB6B*!?;6YT@s1*_r:*jjIVWN?8SPT[V>.M20U,P9l'4iI6TPY-]L!#f3%M(`,YCfUG&+3=,h@oh'%%R8_;#D97$7DPAU-\'4cMbSmaD1quDo:PhC8FAQ_/2XZE4Kg#d',UPm7ke>cGNcuWsA1Re6L<8TPh=9[*Pk3kf]HG?:]j+f^e0da8lF5rcV:E%B=r3G;%R(Xf":ZPhD;HI=o2=W1:skhAOSf)4$6[Y*hA_qQ>#XK+S'ZUkOIKD*iLBqMO1XS"!cLPYd()UE9Lm2lr6Mn03Uc=D9cmg9ZFLR'j#lTAS?p0fFMITB#ShK:pcr`bu\*p_7fncO=H:Cg))Dh,V>4bK>oW$PT7aee,0TKjD0nWW>XIsXWdMeY)H^W"J?KP[.,0T5VP[&"V-R*m\g;oH$Xg-3^E`2UO>b:S!S#%Ni>r1U>7W]WVl%FBJ6EJLK\e5S/p'%Rhg`ig(XQcq,`dM"Z"a`kcZ-'(jE_+^$?7s6^cGj474dI*df2J-e5q=Y_1b16H?P]03X?3K>qnsh^!G`9eSL__s6U1M*9Teo45)s'E#TeBH)kV0Og)S^AO+J(2F[da5RA>ICW7:^P&t'LLAnd0HKr&IpsIn8SeU(:Jc=*pS?k-99YCErn>UJX-`Hn%(aqln*&$XIcANS4VpU[QLj]G!;#@EAKq^@j,u;`/,(/Na!g5q"Yh65\"D,!aB.Em\'n/8"7*<31JeCqa`mMJ:h^-@Y+&*%Hi'pHjq[(V+Huac?`=P/n;ZtVYhK&jU4+P;,;Li0RY7*b9.,B=i>Eeq&&>XEt+0g%csST^gUX`O)f4L?@mpN=*2KGID@n!ahWqW<0.bbeua0:q(o7]2r0OVPUZgknmZaeqoclXGYUp'!2bS=sHp[\G[PG!Smtge^H`:p@^73,cnK$pco"N52fZ7k,?t_TBa6[Yo38a*bPjO'L>&jO>C.hg#O#*qQR%MfmPB/pb=.ds3hbk[@d1B`!QLOun.$sgs3XfN'9kHM]j^-B:=S5hBb`)3Y[+?"%4"O*G7.WL:[M7VEor0!>;%F[GQFZUW-817ADTaR](EM)4B>C4br^N)Q@KkkpNbQ$O`Ai!OQG#u9I'pD\EjH. 2"3sWA960?8;mmK#ZE2_=#C>QJ%q+@gg/`.\j'lY3GBQ_ecS2/`]F/b3$3maOCefRcJ`5!g@1,GaV\/9
Form # 1015 Disability Claim Filing Instructions Have you 1. 0000049255 00000 n /Encoding 4 0 R xref << /Count 1 /First 18 0 R /Last 18 0 R >> `JaOS[A]]e$%M7QS4Qo!meJ)_CS:m7V7-aS4FZ1PGi:"6tO9;>TbWc_tC3LGp(
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Follow the step-by-step instructions below to eSign your aflac wellness claim forms: Select the document you want to sign and click Upload. <> 0000000326 00000 n Claims are subject to underwriting . (V.ea8oM1meVG5&2$R&VHdRmbM`,/jQ'iTTlk_NLi7Pu8>hqB>F6,at#]$=1\UL'_o
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endobj If you are filing for a health screening on your Hospital Indemnity, Accident, or Critical Illness plan for Coronavirus (COVID-19) testing, select Biometric Screening as your exam. ?/8-TEfAU,j[:b-G[DjC57H"+$-Ag(@hZ
Choose your state of residence and select the appropriate form(s). TNMF9_Vr2,SFTeXfUSJa)jt-'"mb39a6fe"7:L*nQB6WHc=tGuKXhdlF@JojFLBR3CIdNL;Gs\omg&R3
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File a Critical Illness Claim via Fax or Mail. "k&*mXEOTDY;
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Life claim forms for the state of Illinois must be obtained by contacting Aflac Worldwide Headquarters at 800.992.3522 to have the appropriate forms sent to you. @mT@XKG9gfV9sjgJ:!#'gnJe-hrK2RiqoM==]mG(t!Vd6O=URG3
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15 0 obj For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York. 0000035380 00000 n "k&*mXEOTDY;
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2 0 obj Learn how Aflac pays cash benefits to help with out-of-pocket expenses that your major medical may not cover. Submit your claim online 24/7 Manage your account, submit and track claims, setup direct deposit and more. 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H? Execute Aflac Initial Disability Claim Forms To Print within a few minutes following the guidelines below: Choose the template you need in the collection of legal forms. )lM~> 25 0 obj h.*.:`/`($FjUjeMh+%3^KDbf? 0000054519 00000 n 17 0 obj Short Term Disability/Long Term Disability Claim Form. 19 0 obj @oGDmsuR-
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/CreationDate (1/24/2023 00:45:44) Claimsmaybefaxedto1-877-44-AFLAC(1-877-442-3522) NY-S00224NY Page2of3 02/14 *LastName Suffix *FirstName MI *DateofBirth(mm/dd/yy) *Employee'sName(LastName,Suffix,FirstName,MI) *Employer'sName/Account# *Employer'sPhoneNumber INITIALDISABILITYCLAIMFORM-EMPLOYER'SSTATEMENT EMPLOYER'SSIGNATURE EMPLOYER'SPRINTEDNAME TITLE DIRECTPHONENUMBER DATE <>stream GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. Take advantage of the quick search and innovative cloud editor to create an accurate AFLAC Short Term Disability. endstream 0000054442 00000 n 0JTM8HGN-uYUmTOelVf]F4AA)ZISHh>(!HVXe#12]a#X:Z;?uk$a0t'3>1o_N(G1e9TB>Kme4`U:>O6e
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Online Claim Form Aflac https://www.aflac.com/file-a-claim/default.aspx Use Aflac SmartClaim app to initiate your claim process online or track your claim. endobj -8KU)@AZCLegJ8ge%BBp0g(_Y&;BmiFJfS%>@Gu7. endobj (q4#=jL^)VnPi.3J&P`.^'?D&jk\gq++JIRRP;p/j8Q)Z,M')M)EjWNe^:g;JhU)j"t=W%Q@J=*Le%l7VZbQ,Dgs8NZs/^)
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Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claims. 0000000446 00000 n 20 0 obj 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H? ;An6Y?l:#h=mlN1\Er
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Aflac Short-Term Disability Insurance pays cash benefits for covered disabilities (subject to exclusions and limitations).