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QE4ts8i6DE)#'2TW-kh'[,&7Z'RGbFcbLB$$`BMM!R'_,b^D2"+(\! <> Apply your e-signature to the PDF page. 0000054519 00000 n a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. ieO?mC^gEt3O?&]\X]CJV6:\OL%X;((>F1o\id;SSBij[G$R FXd-mhfj\dS((^`0K6!.q%j)EYH;^Rd.Aa`hf%gahFK:H:&//7pMV3D2qV#r4Oea\q/upjBMGec[O,Y:5n_u^Q$*P(4j$+WU5q!\lQS0:!H;gK '1L#-Ne#BOUYn.SL> 22 0 obj Once completed you can sign your fillable form or send for signing. rT)4FF1EPoVMN14>L,`\V:)bIb1npmugX^4,7NbhZ&&T,/8(>f=lM4?OnHSHRdi Fill out Aflac Continuing Disability Form 2019 in several minutes by following the guidelines below: Select the template you need from our library of legal forms. c)$el$_7T'R>`H4d?VZZ.6:FXa^5[8hKt_jJ5`+n^Hma14HF`L'+tk,U=9slnfp8]Z?2MS[;()=`R !$"P3qfbXDLeQ[oZ1B!OZ7r(l@ 0000054815 00000 n 0000049332 00000 n 7 0 obj 0000035380 00000 n Gb!'5m[/fJB\_$r.pF?nb0?9.GNU`POZa=?bcjAXQ5kBDO7EHm>6&%47Ab&pW\\Ep0DVbs4$N;\XPZ>cd==.mQbW>ZXE(h&hj!?>RE;`-=j0]K(7>2TZ2c#qP2TZrnnVO>AAO\2\dZ]BV5lN<2g@`o#75u,Z^-1@eCMYZY`nV9iX]Jk15[r)/_I8dD(4^c,bTd,',#!J7^rL)<3a8P7fG%*rf%Dr0X9k_#\a>h%ENsu1N_I/E6"$"4aO%gkZ#_P8u%,_DD4Z3`,&-G'RNJo*@\gVBC#dISL`OXs`X"2c\XYOgQMjo(nU9j@@I>:$?-SG%p\5>K8mf'`2n5g](hjREP0cIi=DlJG%CduFYJX&b.fJg%;BE/2\Y7`WHp'nr&%:J'Y"Od>X7ZKtp1A2/F(Cd$FjNX24)>aWHAi,$d!uihMX'(n_)L`HY6h*Ya>%R%`kI!@VZ@Kj*91XAll1b#)Sj(43C0*ZDYVHW.o&^]8^cs$b>tO5/3)s#"+[I40fCCO0u2)j*3e@/a);GiEC,QcYi&n:D@TcfYcBYeX>jFB"0g]k[qcIUEDh\sY`P3V$amn](*)ZhblK=iC]sei38!J\1:'Sm^g=9F1G?^5X*UTD.c8Kg>?CNpfj;t*;*+5-3+-1$][#p+$s7LY3ds$(WS^3ipt1n?4gpo(-)4hZ]5TSD1c"b62Ae,uI=ht5%%pur?]C"mK+/"n@,G@E!%Tm_Z('e6`@=LQJX>m2u!EdFdln=`n_1KT(Jdtn&@OhFd_-qh%AS.4e_"nG>AmU@I`/XL)S*AH60oN#\=,_M)mR[KZ"p#@QKTXhSQoBW6Pc2r1abgMO4mbWZJ_P.S0Z?CC27h1I4*Xt]'k^P`c1tChMX"]cTFjUN>O%@eLs@rgmWT?ci5AXtahm=GCI0lG41Vu%ET![Pf]&aI:B+JKG^84P$0u2CD+0?/0su!u;km^rug0:2"VI(*%/+bQ/)HNQVs0JlC_#J`D*lKqGe.5CT5W%::0+m=,"tDhT:Jf.Zq_h(jA)][.]!1gIc_g$e.NIY7[Dn[]g&+*Dc(B:jSF2;0_UcSO=hWJLHLeZ$&=Ibr9.GHm'mXS3P2Ek.5Ya!YtUFO)#kgZ.eZ`LC0e]4]aW"'asKdg_Z"5EE^C=)[U)8)55iHZq2>kKE;Zj.Do+X/DSW[g,Q>hSOSQ$%5h_?(@[q&hh1R=9+/)8;"A^Hn>PPi5t$eN5g`uORs-`,rNBc0.X_)BIVn/qs?1NU@,SCi]^G`[P0TK1pr%^qAZJ4DVn/T'u"#MW0u^k8/G"%kaRF,8qKUN? Your employer is responsible for providing the information in Part B, and your attending physician is responsible for providing the information in Part C. In addition, please read and then sign the Authorization for Disclosure of Health Information (HIPAA form) included in Part A, as well as the separate Authorization for Disclosure of Health Information (HIPAA form). endstream endobj Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F 25 0 obj 22 0 obj 0000037564 00000 n 44EBCGZWK1$09&Q#o?-4-.oof+30H,2'QUFu;$7Pkc ?&2QmV4C.$NuL;0P(Z7tk6M /ToUnicode 13 0 R 4 0 obj 55184 ]/:~> 0000037564 00000 n 9 0 obj 20 0 obj 10 0 obj >> Get more info about Aflac for business owners.. 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,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R endobj 0000000814 00000 n @lR;bed"/KM4=.N)6,FfJ&AfVrJm-US /Subtype /Type1 endobj endobj startxref 'oHV-TGH;:1osTnm1H 22 0 obj N)G#g,5CuOCl3ttm>moVq5\t:irQ`YOX`hI[-7k@LAI*:FcS$CfJQIJO'l@aSJln)/KXYQh;4`]9N;Qj Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the Pre-Existing Investigation Statement. 0000001422 00000 n endobj endobj %%EOF, ^#$J_1B!E\jQnDo*AZEPW#Q5HmqO\,o&d+LqKX0];I^YQ!dK5/)RRb8kQ;c1SD&I_aWfY7X 0000003079 00000 n 0000040092 00000 n [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~> And the best part? endstream CAIC is not licensed to solicit business in New York, Guam, Puerto Rico or the Virgin Islands. 32h0$$08-8TYS-cMZH4Z@mV"tA/C(INdbs#Y3A\%VXCNMeOT)V?mHH\@]`s8D$dlP#B>-]=L]c3bUZ5nds%jlGpH>? 0000003079 00000 n 0000000563 00000 n ;:9bBtb9H]qk\bkhPfIu$"+1TVJFo3OYhdrtnn;;,mTF]?KG*]5oEoE,[rmic= @N)SrO2ugDjIc8hNYmK#n+u6M$%s(j[C@]^p/k/% << 0000049255 00000 n ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; Please fully complete the claim form for the Wellness Benefit. stream Get rid of the routine and create paperwork on the web! /Encoding 4 0 R /CreationDate (1/24/2023 00:45:44) 3 0 obj <> GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. Please submit the pathology report used in the diagnosis of a malignant cancer, the claimant's birth certificate, and any itemized medical bills with the diagnosis and procedure codes, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). 01Kfu^/nVO+L(Jdq73kWrp8S-B^0`qh,U[o.OS(9*S//rm]sB[#0$Ikq. Explore the unlimited potential and flexibility that comes with the opportunity to become an Aflac insurance agent. _^7`jFRJiik^>[sr;K_R=oP`RhjIDn7[PIg5,_,"obk"U42[,7b`:kTqB'Do)liYcA9l:=H+qjE). $s?SXVcf%'C4RJ(8`-)k.!R/tmOC4@"`:#!%j`_M[6BFOHB#O$NY5c1rOEh=kBspt>`NP'>;a[EcIDPt 44EBCGZWK1$09&Q#o?-4-.oof+30H,2'QUFu;$7Pkc Our customer service representatives are here to assist you Monday through Friday 9 a.m. until 7 p.m. Eastern time. D3IFAAEDU]W&`=8ZQHFkEqDQ^[Kaa=!=[XM/$T#Eb_7Ual%dq@k@o8>0@u1oQdW.1<0#6L^ZrQRcYr_T endobj Mail: Post Office Box 84075, Columbus, GA 31993, For critical illness claims, we need information from you and your attending physician. endstream (8p@RL@:%uhr=mo1Fg6rg/M;<4* :0&HC(d$*r1.Y<=jD`$Ia7bVR3*X"Pd8ODQ(-pM4B8oHgR 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY ^D"tO6srOZFP9$! ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d The Attending Physicians statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. _0kQ98&!$i3)qj(aoD$GE4ichZTh10fLUX?o`T)Tp(DKE$D,A)o)nXcqGjE4Kf$SW?d(38p]9$)m%!a_ endstream This form may be used on all product claims except Group Term Life, Group Whole Life and AD&D claims. 0000054519 00000 n (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/^) ,-TQAaYC[5-ru"XbG^9qf`7Q_V*TD8eW0!d4tTL2](RU^lH!V+k6L3^9)d)_:\E P;j%5)jo)E)Oa&qP(Ph7/Yj! (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/^) "\1ceiPob[!+@J3(3TJ)YX)OUj[W9&;I:dYZ=kc)4eebY'g`kA>>[&O][obn/UEdfgRXrat28;.HM:HQa#NGoYVo#="o%! 0000001020 00000 n Submit or View Your Claim 02rhl21qBSA"(T]mcU-(M+$l6hA!\lUur6,-iT#]. ,-TQAaYC[5-ru"XbG^9qf`7Q_V*TD8eW0!d4tTL2](RU^lH!V+k6L3^9)d)_:\E 29Q-bd"lOXj_`+YYr:EA4 ^$F!_M^D.n0(qARn(aE/AgY,iIM9"8CcNDqjSN*8m)"S@.f==Xc1]GcbA-_LZ\:A:pe2tj endobj endstream endstream /BaseFont /Helvetica-Bold :0&HC(d$*r1.Y<=jD`$Ia7bVR3*X"Pd8ODQ(-pM4B8oHgR SUPPLEMENTAL CLAIM FORM (CONTINUING DISABILITY) (Please have completed for support of continued disability) Claim Number: PART A: POLICYHOLDER'S STATEMENT . $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR /BaseFont /Helvetica endobj <> FXd-mhfj\dS((^`0K6!.q%j)EYH;^Rd.Aa`hf%gahFK:H:&//7pMV3D2qV#r4Oea\q/upjBMGec[O,Y:5n_u^Q$*P(4j$+WU5q!\lQS0:!H;gK Aflac lets you provide your employees with outstanding benefits without costing you a penny.
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