This form may be used on all product claims except Group Term Life, Group Whole Life and AD&D claims. /BaseFont /Helvetica-BoldOblique Simply select "File Online" below and follow the instructions. @oGDmsuR- >> Beneficiary's Statement for Death Claim Form. 1 0 obj 0000000009 00000 n '1L#-Ne#BOUYn.SL> A(lCW]h%VdMt:8Y)JTJc(@p\,K2F73Vt)lr]_VGs^b4MoT7ZmT:ZlP&6C?-PWabHK;JrCnJnrcc V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT /Encoding 4 0 R oJ!qE004N-XBk;7k]qo&bs<9Pm9 ;]2"WH3RN-IY-eA348fl;R6]T4%O*^emkHfI8Di4T'&!Ns\94;%b *-ogCe2UsEgf\'ds_/jiZfh5I(c[]]fP=H[DUhhQ4'/;X2hk?KsbO!`rDQ2eS&bFI1P0&@J-^!k9`KO(igH\q^TX%?G:9) 3mQ%,1)gj;9$&S!\%GgUIJtYQ=_8pbJK)n9=AhVBAWh/*_5LS#%,`3%e$TMO+0\q]13BVh1cl87bY77Q AkJD?1M>up>BcsX+I=_#LC$k%qGLcEUfd4i%!i& CAIC is not licensed to solicit business in New York, Guam, Puerto Rico or the Virgin Islands. 1g!5D-LsIWRBY-X(8X2r&@O_`0*:d@O.-Wcm!Ja'h?grDR1Nq&[A-=2b! 0000040092 00000 n The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee's Form W-2. *-ogCe2UsEgf\'ds_/jiZfh5I(c[]]fP=H[DUhhQ4'/;X2hk?KsbO!`rDQ2eS&bFI1P0&@J-^!k9`KO(igH\q^TX%?G:9) 0000000326 00000 n m);lB2NZG/rMHahB@? Check if everything is filled in correctly, with no typos or lacking blocks. *PolicyNumber: / / - --PatientInformation: *LastName Suffix *FirstName MI *DateofBirth(mm/dd/yy . 20 0 obj 0000000000 65535 f << endobj lPl9tY-IJ%_lFQbBP+,UB6!AO?&Q*kaBs. IsNhEk,PeVb^BZe[*I4rabcN&lDZ'ULHK+-T$;u]WD3GH('p*58J'[(3mgr(:*0TR2iG4M503dao>uU! endobj mhQCujn[DM`k5Vu9TL8/lY,n@)69`YnLctGSmP1C9g-Y\7nk0=`m#b/(aquK(k!OU2OhA)L%au^_^KfM 9 0 obj 0000055102 00000 n 25 0 obj 0000055102 00000 n 01Kfu^/nVO+L(Jdq73kWrp8S-B^0`qh,U[o.OS(9*S//rm]sB[#0$Ikq. TiH!-bXfof5[n@&[kS/JgZ:HFlTDHBWer?faRZL 17 0 obj Please complete the Patient section, Boxes 818, as well as the Policyholder/Employee section (excluding Boxes 3138 and 40.) 19 0 obj endobj FXd-mhfj\dS((^`0K6!.q%j)EYH;^Rd.Aa`hf%gahFK:H:&//7pMV3D2qV#r4Oea\q/upjBMGec[O,Y:5n_u^Q$*P(4j$+WU5q!\lQS0:!H;gK ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d We built our online claims process to save you time and to help give you peace of mind. ;PmE,29/@]Q_gjie3>F*fbNG$7H6^5^trSgt@MX18^JE+B$K 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H? /I1 14 0 R /P0 15 0 R /P1 16 0 R /P2 17 0 R pVm0rYNePYi@2CrKlf(0`O9(:4lsA`"DB*V_2?OtI(:IK1s$SV]W0j\bo[2VhWP2Ff.O9.oYUrAMp$ DCl*mJUg=pq^:YnVX2rH-?MoX;V+!pDt12?)+Ag/%cNZV^V$#m+E*A#TQr? h0cQ^!FY^@5YZ9`C((MZ9iSNHc>@i(/A6Ang=Q>29[%f,N\.ZX(j>Mqs0Q)QK[VqWr`O1c][Ae6 endobj EMnIpA`\`j9p%8Jb%g?3bB@@W^$A.t>R)@AV[$Gr+1aic5NY;`=A9#XB->:2MDO^@t[9!^9`hM)b9[&5Hfki>iJ2*idRMc*I1K7B)P.Ht.`'k-.R`,bZ1``cJ No Yes Isdisabilityduetoaninjury? endobj (0h]6sfh&ctrb/lSmDh5-O.iae,IL6uU^p;6R$coc.i2=RBLFrO3lTLkd^8 Request a quote dialog. /Filter [/ASCII85Decode /FlateDecode] 3OKN&2W(XWj*4Pa1H50U%qWra$*VdVbd3"%Mqma1p?g8L8>2.+8'p^s14V/euOX@S5` 21 0 obj endobj 0000054519 00000 n endobj O!61!%9G.V^/"+$60K[1j:%8%V^jr#WgA)E0dmgaHYP)uTIcfaXm(sZ9L'dZ;nA@OpWjJ1,O,)*$t/$< !G5'>m!$kI`%E,=&c9e1!`-(ln6%1Abq7/PK2;m`V,'D51([Fj 24 0 obj jd*ZcXe"_QS4SaSM0H8\:kGm7EGchf:.,NK]?.0?7FYh&?aae5>4\THpn]0*9A8N Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; endobj %+7qEQTFU"'i_\(/=gq+JNS@%Y-$pZB>:Y4*(rCZfQj@Kgqq^GWEccM#up\R$:Ie]Cf@mqFQ&(pWqBMr ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d CNbe58Z\L9(JIf#nd8N&d;_Ve"&$B6Y;]TiZ`M2[D^dN\Eb5qm'qVJ='T'4DBH2tpG-/Q,o_g=%ZaF:Y -8KU)@AZCLegJ8ge%BBp0g(_Y&;BmiFJfS%>@Gu7. 02rhl21qBSA"(T]mcU-(M+$l6hA!\lUur6,-iT#]. ?NAW /Type /Font 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). 18 0 obj 0000000212 00000 n Choose your state of residence and select the appropriate form (s). Download the data file or print out your PDF version. endobj TNMF9_Vr2,SFTeXfUSJa)jt-'"mb39a6fe"7:L*nQB6WHc=tGuKXhdlF@JojFLBR3CIdNL;Gs\omg&R3 mQYc=\E9,ERP]c]=8bqqqY%CP/fB'k8=no-Ws101`o*'eZs]oap*qMF (8p@RL@:%uhr=mo1Fg6rg/M;<4* *WS>mdrX4a@K:\2X]Y(aJJnXSIKj37?5&F)>s:B7il/.16"r!2ThTJ5PA3j'f^*7d4SNu%N>--MA'!$L 2@Aq[=+(TD3oRc#`>K/0ZNjU%/:30? American Family Life Assurance Company of New York | Albany, NY Please choose an option. In NY both group and individual coverage is offered by American Family Life Assurance Company of New York. Consider filing online for faster claims payment! P;j%5)jo)E)Oa&qP(Ph7/Yj! <>stream 24 0 obj Rf;iu7gGe[$chW^;W6Fl=BqZ%6KIFZ'HNb5)TaYYGG:'$r`) endobj 0000000000 65535 f HQ$ujRc"9@)AC83@/u';(.AU@8h[,dM5@MBi91i8@]+f5P8hFJ11.%Ec:Brs4lZA';_labWMQK7-EQHe TLFC\4aS)n5C^j*@4%"P0VVa9rj(. 0000043507 00000 n 0000000563 00000 n 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^? (@(usgg(FDHdtq_aekmXE(BC6eG1C/8GXuO:=']]5O,*cYeJ6rL_T-&cqtYOG-PZ=N]XFkICN-m,r>>:_tp?- :0&HC(d$*r1.Y<=jD`$Ia7bVR3*X"Pd8ODQ(-pM4B8oHgR Yku1YRdk^9;TD\;*kl4jYjTa8Xl"SC:fUS)e;!AcrDK#l16`LFaGhEJ;`,G>'H*8^Jr\^>/E?FZ]1S?b :^_n)prV#UtcF7_C)h7^7 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). N)G#g,5CuOCl3ttm>moVq5\t:irQ`YOX`hI[-7k@LAI*:FcS$CfJQIJO'l@aSJln)/KXYQh;4`]9N;Qj (8p@RL@:%uhr=mo1Fg6rg/M;<4* endobj endstream startxref Group policies are offered by Continental American Insurance Company (CAIC). 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; ]_h\LUlKWpDX[03gS"tG,UJ0*mL9UkEk%7OIX,#u6?P_/\,44Z>m2`cW$i)b*qRV/6raU^h/W^<6?6JC;$U>eK_"kZBZcu]&\dTh"\!Q%B8?1?Rk8,^p^Wn[RC5_%c^'XQF+or endobj Please provide a certified copy of the deceased person's birth certificate and death certificate. 0000035380 00000 n 11 0 obj _0kQ98&!$i3)qj(aoD$GE4ichZTh10fLUX?o`T)Tp(DKE$D,A)o)nXcqGjE4Kf$SW?d(38p]9$)m%!a_ ii0)@:9O(%@H%RrdWERj>N3*\BUO1i]tqg3/1[H/;eAHS(@In[U#O`g'CB(1Z@f9[-o$S-AZ%3&Ipb== 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; h0cQ^!FY^@5YZ9`C((MZ9iSNHc>@i(/A6Ang=Q>29[%f,N\.ZX(j>Mqs0Q)QK[VqWr`O1c][Ae6 ffBW;,%_AN*"_VFk^*[7l*M'q?n=q..L?F%d startxref TNMF9_Vr2,SFTeXfUSJa)jt-'"mb39a6fe"7:L*nQB6WHc=tGuKXhdlF@JojFLBR3CIdNL;Gs\omg&R3 p!WHg/S/1>qh13::;;66rN. 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). The Attending Physicians statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. 0000003079 00000 n 26 0 obj And the best part? 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"D=hF9Hc;3b+uU#87#u->Oo&ZR/kmg`A@Va9ssE1`$L205UY2\m1KJ?'g1*p?gL[/Z6a.dV! Managing your coverage has never been easier. IgeDH7TM\#pU10L#Ss`6=>>>RJf3(u"SS*/4)kIZjBeggFpXisbnT"]8aV=2.gG!O"):K$0*DuMhDAGnARk37 P\D=1Pt+K^bCr/L=R_+?]7:K8ND*^rZJ>\)+SO$sqSJ1VT+A'Q-ShdfdhK\Q%N%LoP*mTJ1U1["BmoP?0"U1GH. If you are contacted in this manner, please call Aflac at (877) 499-8606 and do not provide this information. For groups sitused in California, group coverage is underwritten by Continental American Life Insurance Company. Coverage underwritten by American Family Life Assurance Company of Columbus. Life claim forms for the state of Illinois must be obtained by contacting Aflac Worldwide Headquarters at 800.992.3522 to have the appropriate forms sent to you. 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[W_J1(2pZ1HC$V;V*/7\3N-"m8ACA6(\G4_j7tLZo4PDu:9kltQ:qtrOFJei`3u25)_cfnQ2M,M>*2Sb <> !^`!O2!InjU(e3U7YceUPSbUm,".#RY6kVt+9Vg5'L]Mt+EU">H4*U`'^6l6 0000040092 00000 n If your injury occurred on the job, a first report of injury filed with your employer must be attached to the completed claim form. /Type /Font ^f8SP@,%81kYF7&7>W`>g^5VpKEtLo)BHCQ9Z^%VoU(+& TLFC\4aS)n5C^j*@4%"P0VVa9rj(. 2&Tk-bp^c+fLgI$.,d5^! /I1 14 0 R /P0 15 0 R /P1 16 0 R /P2 17 0 R :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! <> /XObject << QE4ts8i6DE)#'2TW-kh'[,&7Z'RGbFcbLB$$`BMM!R'_,b^D2"+(\! 0000030858 00000 n endstream endobj 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY "k&*mXEOTDY; View details, map and photos of this duplex property with 4 bedrooms and 2 total baths. <> /BaseFont /Helvetica 55184 GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. endobj endobj /Type /Font "DFX!Fen1$B29'W4#sWKq startxref $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K endobj 0000037564 00000 n ieO?mC^gEt3O?&]\X]CJV6:\OL%X;((>F1o\id;SSBij[G$R ?M?uK\`[L'MVpgq.\;DFhc?I3,E@L<5O.H'In/5-%oHIk6Y].-91Vsi8;^S7T-@bW-s/Y'OlKTsB7_NY 4DJ',H9cO;3i^o\C+^QV'V04i8_]sBSS$("j]B+50E+CQV5b^gW\=h>i@^d/*Zf(82"&uJ.f5ea9kXJ@ U;s(7Es'Hq&:@a]^0oUGCJa3R7thK`//"XdS%5f,bl:[\>V0EGJX9:R[P$&(L2fO4E"!r*bnZA.0JbrSKY5@2H. 20 0 obj EMnIpA`\`j9p%8Jb%g?3bB@@W^$A.t>R)@AV[$Gr+1aic5NY;`=A9#XB->:2MDO^@t[9!^9`hM)b9[&5Hfki>iJ2*idRMc*I1K7B)P.Ht.`'k-.R`,bZ1``cJ TJ(bq:!Ce_pc=2B1P"%7$HG=ui[FCuL+*6":'=rM2is:GPB$q%ZHU@,+FueOi0ob+.\6Ek;q7r%XbW$S 2 0 obj xref ;PmE,29/@]Q_gjie3>F*fbNG$7H6^5^trSgt@MX18^JE+B$K endstream !om"/\*lLc;1!=2VJY6B8M#SQkFA/PescpqBeho-)be]?.9:k-Uth]7P9'K8#,S=r#]\"XYE-i- ::bl''..9BC;a\$BlT\:t-X,fsW*QN`2e(KL 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).
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