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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). 0000040092 00000 n Had your Employer complete the Employer's Statement, and had it returned to you? *Jn&hZmHE?Eu$9%^_jrU\Fh>uH`k,8rK )toiFe(5W*JmS'IeRpMhRM\E^RfC)>n7:/sPgsY5E^.`.P>\/9SK;2 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H? 0000035380 00000 n O!61!%9G.V^/"+$60K[1j:%8%V^jr#WgA)E0dmgaHYP)uTIcfaXm(sZ9L'dZ;nA@OpWjJ1,O,)*$t/$< And the best part? 55184 S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/ai^g,u(4jLe=m[4V59--p2Tap(*UC^8Qur;jVC%5c7VaBB+,0AUKH@dUPF5MD 0000049255 00000 n Q[WGEfLmSJlD4aAIQg]>]O"6oFV!6AQ*&I%W1?E?iS+o&0c^Yc&U1]$I6mp;f=sCk)`?#3^FVJTgJrGe_1^q4-mOnYK@c1T5eKoO`M^;`6u-:]MC=Xh]*G+XUYfH(M?5 endobj << /Count 1 /First 18 0 R /Last 18 0 R >> &>7[>d7(qqN/lSW8,9((\,+tAibO:g1>Tl'K;D\HUqeC^#X0pPUXu3oeqYppd\O0nI(-OoF3]X=)@;7_ Q[WGEfLmSJlD4aAIQg]>]O"6oFV!6AQ*&I%W1?E?iS+o&0c^Yc&U1]$I6mp;f=sCk)`?#3^FVJTgJrGe_1^q4-mOnYK@c1T5eKoO`M^;`6u-:]MC=Xh]*G+XUYfH(M?5 Apply your e-signature to the PDF page. We built our online claims process to save you time and to help give you peace of mind. << qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib 18 0 obj 7.XdOm?gqE4o-8r9 *?ZgaJ72F%->d4aYIUb3reE0'[sM)3JY+[(7="R\fM6;Q c)$el$_7T'R>`H4d?VZZ.6:FXa^5[8hKt_jJ5`+n^Hma14HF`L'+tk,U=9slnfp8]Z?2MS[;()=`R :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! endstream CNbe58Z\L9(JIf#nd8N&d;_Ve"&$B6Y;]TiZ`M2[D^dN\Eb5qm'qVJ='T'4DBH2tpG-/Q,o_g=%ZaF:Y GtHt%Nh;7F1(!K[n[8/1g\PTUNaGT"=n\Bb:62T:Xt#[Q]!mJ,M&0#sD9($J$JR;eXA\0%6Xp-RXgTNJt5f^? )lM~> Aflac Worldwide Headquarters | Columbus, GA 0000000563 00000 n @mT@XKG9gfV9sjgJ:!#'gnJe-hrK2RiqoM==]mG(t!Vd6O=URG3 >> 19 0 obj No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . 1420 W 1700 N, Provo, UT 84604 - MLS 1864947 - Coldwell Banker endobj Follow our simple actions to get your Aflac Continuing Disability Form ready rapidly: Pick the template from the library. cC5a$qEUFt(E8e->F3f^Yr:J8cr+o+V8SWC.sUDP!9a:YTD`h-6Dlku'HCEL>"u[SakEau 4)&nf$tE5"g*2#E``6gl3H_U)RH)m.VU*-AYq=+#%i9Y7;)=6rhbKN=8id"8PGV#c1SW%K9D-r,8`1lZ >> [W_J1(2pZ1HC$V;V*/7\3N-"m8ACA6(\G4_j7tLZo4PDu:9kltQ:qtrOFJei`3u25)_cfnQ2M,M>*2Sb D3IFAAEDU]W&`=8ZQHFkEqDQ^[Kaa=!=[XM/$T#Eb_7Ual%dq@k@o8>0@u1oQdW.1<0#6L^ZrQRcYr_T Filing Claims | Aflac Group <> endstream Request a quote dialog. 25 0 obj %PDF Font (F49) <> Offer your clients better benefit options with Aflac supplemental insurance policies. endobj ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; 7.XdOm?gqE4o-8r9 0000000446 00000 n endobj 0000000009 00000 n 2"3sWA960?8;mmK#ZE2_=#C>QJ%q+@gg/`.\j'lY3GBQ_ecS2/`]F/b3$3maOCefRcJ`5!g@1,GaV\/9 endstream Check if everything is filled in correctly, with no typos or lacking blocks. 21 0 obj IsNhEk,PeVb^BZe[*I4rabcN&lDZ'ULHK+-T$;u]WD3GH('p*58J'[(3mgr(:*0TR2iG4M503dao>uU! << /Count 1 /First 18 0 R /Last 18 0 R >> 0000001020 00000 n 0000000212 00000 n 25 0 obj DCl*mJUg=pq^:YnVX2rH-?MoX;V+!pDt12?)+Ag/%cNZV^V$#m+E*A#TQr? 0000043584 00000 n 3 0 obj <>stream xref /BaseFont /Times-Roman /5&*Q)*,WjJn8+=I9EJW%)B]4Nh %+7qEQTFU"'i_\(/=gq+JNS@%Y-$pZB>:Y4*(rCZfQj@Kgqq^GWEccM#up\R$:Ie]Cf@mqFQ&(pWqBMr <> endobj /Type /Font Form # 1015 Disability Claim Filing Instructions Have you 1. "kt65Ko1TNq1+;X4?fH1W0SbI2D-F(6cs2(!E?1oM!HZ/`bJ.Cb4@4gWrBVNX,G01o;?NA0^%)?aS>EJ T9khijaBNZR9C,%t"7Fg@HCRo`)?gN`jH7$+&;F&1h$f-gZ@qpFS8g[qONg*?3muhSPi%q01m@ D3IFAAEDU]W&`=8ZQHFkEqDQ^[Kaa=!=[XM/$T#Eb_7Ual%dq@k@o8>0@u1oQdW.1<0#6L^ZrQRcYr_T 0000040092 00000 n endobj The University is committed to a policy of equal opportunity for all persons and does not discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, or veteran status in employment, educational programs and activities, and admissions. endobj endobj U;s(7Es'Hq&:@a]^0oUGCJa3R7thK`//"XdS%5f,bl:[\>V0EGJX9:R[P$&(L2fO4E"!r*bnZA.0JbrSKY5@2H. )lM~> 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^? 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N)G#g,5CuOCl3ttm>moVq5\t:irQ`YOX`hI[-7k@LAI*:FcS$CfJQIJO'l@aSJln)/KXYQh;4`]9N;Qj 0000049332 00000 n Simply click Done to save the adjustments. How Does Short-Term Disability Work? | Aflac @oGDmsuR- 2@Aq[=+(TD3oRc#`>K/0ZNjU%/:30? 12 0 obj CNbe58Z\L9(JIf#nd8N&d;_Ve"&$B6Y;]TiZ`M2[D^dN\Eb5qm'qVJ='T'4DBH2tpG-/Q,o_g=%ZaF:Y 'X-2uc/>cM8\5p/T44i`BgV5"LY/5Yg% Log in to to your account or Chat with us. 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). :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! ;An6Y?l:#h=mlN1\Er In CA, CAIC does business as Continental American Life Insurance Company (CAIC NAIC 71730) <> 0000054815 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/^) Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F J"!Z$KNf!aNfZg$c3f9Eif:$>6XgnJ_+WZ+>UN`D_090Sk6pr-./XCf.RcJoIeeA$283Wm0>IEa1k;_GenLoF#=W7kAbUSPPYkck"W#[d8g/CEK/Qj&fT8,quS8O4;583SMLnm&$C16R.4cCjYs)h@>WY-)F jPHFW8nlme]HU. 6,k1;gaBDk.XY%J:F9As.#C&J>pqd^X_`2(g"7EVNm@*ELI1%cI mOu72$0Z_TEkhh3=;Da@gQ!"PXflT9`-nbs>;ZjA5? (D;A)'1,bTSu(P!sL=W[AP?iW[gGM /2R!i5j&PBRjtAnemGT^T>r)/aH+##c99WL>k&k>=:> ;dps@dXdX$3sN65dLrqK;34,XZ>#G6k1;= 0000000212 00000 n Please provide a certified copy of the deceased person's birth certificate and death certificate. 3 0 obj If you are filing for a health screening on your Hospital Indemnity, Accident, or Critical Illness plan for Coronavirus (COVID-19) testing, select Biometric Screening as your exam. <> 8*C9[J(Cl:;Gi9qfiditHQ#'L]jC2sPgd`'`W#[3J"LQg0%?W3t_5VRgmCJ5=M#ORRY\sAH6Rq;5+ChV$?jn,^o9SGo>Ha $s?SXVcf%'C4RJ(8`-)k.!R/tmOC4@"`:#!%j`_M[6BFOHB#O$NY5c1rOEh=kBspt>`NP'>;a[EcIDPt To file a claim, simply select the appropriate claim form for your specific product and mail or fax it to us at the address on the form. Self-funded plans and absence services are administered by CAIC in all states but NY. jd*ZcXe"_QS4SaSM0H8\:kGm7EGchf:.,NK]?.0?7FYh&?aae5>4\THpn]0*9A8N \&)R4M>ms@. p!WHg/S/1>qh13::;;66rN. endobj stream 21 0 obj 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; endobj 8e==QcdnYk8&(`lkD;,]b;+SbfrO-.*]B,RLFCV[]Pa\Z? View Site Continuing Disability Claim Form Aflac https://api.aflac.com/docs/claimforms/S13270.pdf Claims are subject to underwriting . -_6'A_4IL[`92un&r8tH[>^"rhOWrgJZC\%6"6'k2kR6&.9EYCGWVonkFA2[(WQ.mndG'-IoKK^(VM6j):K)HmcRL+qg#Rf )F9)MP$gjIIV>!H Payments can be used as needed - to help with medical bills, recovery expenses or even to help you pay for rent or groceries. 9srK>"cZ(SQ7f&_@XkjoOD9.JoV5["B)lrLk1"RN#NAQ@Io/k:h_VaFk%A]Xes%eU0Lr%f7V@nha@^3[ $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR _0kQ98&!$i3)qj(aoD$GE4ichZTh10fLUX?o`T)Tp(DKE$D,A)o)nXcqGjE4Kf$SW?d(38p]9$)m%!a_ 2"3sWA960?8;mmK#ZE2_=#C>QJ%q+@gg/`.\j'lY3GBQ_ecS2/`]F/b3$3maOCefRcJ`5!g@1,GaV\/9 24 0 obj Aflac Continuing Short Term Disability Claim Form Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf Please note: The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee's Form W-2. 0000000446 00000 n j`\4ST^,:jc\SuD`L1I_)i;e_O'6;f$b?pm]7fCb6/VFNc7I[fZnuXU\MA`LdJnpE 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. endobj ;PmE,29/@]Q_gjie3>F*fbNG$7H6^5^trSgt@MX18^JE+B$K +-,&SN`[I-M6qW3;r1s0&Z$T=BbN][5p[;h9H7KL(+uC\p]Q8pinC7ha3-F4WH*,lCOr\XdV:L)GI3LX V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT 0000054815 00000 n >/FRGOB+OB[1iVR22-7Lnt@)K1T_gY[7;kiM;`1C&61:AoC42ST7*!-T+uZ3:t]s'Eh(_u3^02+HBBV< endobj oJ!qE004N-XBk;7k]qo&bs<9Pm9 0_FaA2c"TR+Z*/NX]@%oAY9.69"_+1=7k*G8lpq9SsA(A[jP@=?-.Ye 20 0 obj k0Q'9K%4rkrrN3]cu8p8';m8q-eHY2Sa?q0DqdO_]i_5()gWNP#-%H8k&XV=Id,j>)pb@S-4-ot]OZm4 /Encoding 4 0 R <> Bk\1f/VUX4ST4NT40lN34+-*[pI_iW#ggd2*`hgWE^=-R:s=)2'tu01Vr]^_S>-&.RS7)o+'X@(Y83/( 23 0 obj FuFfnc;)7cKg['Zqu$@#^.Lm;P)OIh\R^_`-@):D`Br-$pdOd.\.5Vk2j_jL6C'[%-[(4 endstream ;PmE,29/@]Q_gjie3>F*fbNG$7H6^5^trSgt@MX18^JE+B$K Direct to Consumer Business is underwritten by Tier One Insurance Company, doing business as Tier One Life Insurance Company in California (Tier One NAIC 92908). endobj GgU]JcO2rI@MJ!M*4mh6R`a.PLnCe-ET<>a;*-c;Tf1f Data Analyst II, Information Technology, Dell Medical School - Provo Gau11gQ!:3&4M)fO+Bqq68hgpo*+gp=2Y]D/n"iL.5,!&rqt4]k:;$A5NLFAhtQ5bEOn@#^,c5cB!.a)bI[X^$Z/(6Y3*HPeGm7X6?U'%V=rC9[=GjqjWB0seXj;VlVcTeq5_9FHgWfdVe$=P]!o`0j\1-`^3>_A9ZoUTo$WJK1Q:]6WWAVuKI'Y$35ml*7PtOu0J6e7#&o=%qn3o`.E7sK;/h7%\$[-i.7V$.UYlP*?.uFbc7nhCFtIZjOkQrAc7g"Ug9r:8cEafo8627jFXKfYC0A$S9usZ2SDC/"#[+d*"'o%^Q_*Hn&@1AgijL%'P.Kf^i=oG0s!qIUL=aJ[)T&lc>&&=C!Q>:6l;0*KDgPp:O0c64SqnC,A;6e(b@.p,;O[!?.Sna&[9^L-dYtESB'GStL%:JFBKQc+/Jhmi-fJJ+7%.r1/J5_ETA"->7L4LD8#&oV*>h\"h(P@^^V"G:N&(p,Bpn`G=k7^Y24.eZ+fU&nc[ckh*cU*E"`DO?WcV^7MJqO'=*3e@o(GH)q32NcZVm,*P7[jK\S5O:+;g@Z5G1ueC"UB1s*3eFeRT>urJqNo1%TmZ]iAKK)'F-cRCQ'b5Gu'h$B>SH,oFG&_(#Nh-lC&bUYsd4"b6Un)pIJ!J:`@=9V^Ou@'51a'T@(>@7J)e!"09oCFq>.M?=XG>0X\o#JKEQ$E-(V^%OrGecoP1N*FRX"Xk)Vh#!Kj[50561k9'CWJs"cU",4`-[FLuf/3'T1k("0op(&%Fi1RNI"'1rI5@hQ]KA(&M=E%)@blK=ilBq])3%^oTlln@er)QXZj0ed[F%F_4[8.973"HF55CWkf:K*@$cO`\BrPBm60$P! /Subtype /Type1 (8p@RL@:%uhr=mo1Fg6rg/M;<4* DCl*mJUg=pq^:YnVX2rH-?MoX;V+!pDt12?)+Ag/%cNZV^V$#m+E*A#TQr? 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View Site Aflac Initial Disability Claim Form Capital Insurance Agency Aflac Initial Disability Claim Form endstream aflac continuing disability claim form Summary of Benefits for Benefits Eligible Employees Mar 31, 2022 Employees are covered by long-term disability insurance, beginning on the first day of employment. *#*-ScS*/MMA_!%)m!2N2g5V( trailer<> pVm0rYNePYi@2CrKlf(0`O9(:4lsA`"DB*V_2?OtI(:IK1s$SV]W0j\bo[2VhWP2Ff.O9.oYUrAMp$ ]n9eB$>Q3/Zh8hTCilrgR.+jiDh,K#srd-U9acuKPd@,V`j5BhbA8I Aflac lets you provide your employees with outstanding benefits without costing you a penny. @N)SrO2ugDjIc8hNYmK#n+u6M$%s(j[C@]^p/k/% 0000035380 00000 n 0000001422 00000 n 5]mS)I&\m'[NsCj]sr@0El\`]Uq+.S367pgfd2I2(=P['dU+EV"7XqK'c7K%if?fQ]VP A BenExtend claim requires supporting documentation for review of benefits such as an itemized bill if there was a hospital stay, itemized bill from physician's office, surgical report if surgery took place, Xray/Diagnostic Test reports with dates and charges if applicable, accident report if applicable, and a signed and dated Authorization for Disclosure of Health Information (HIPAA form).
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