Accident wellness benefit claim form some of the tests listed may not be covered under the wellness benefit of your policy. Continental american insurance company caic, a proud member of the aflac family of insurers, is a whollyowned subsidiary of aflac incorporated and underwrites group coverage. This form is designed to provide an annual cancer screening after the first 12 months of insurance, for those who have the cancer screening benefit. Please submit the pathology report used in the diagnosis of a malignant cancer, the claimants 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. Claims department, worldwide headquarters, 1932 wynnton road, columbus, ga 31999, as soon as.
Download aflac accident wellness benefit claim form pdf. And since we can process your claim quickly, aflac helps give you the peace of mind knowing you can spend more time recovering and less time worrying about bills. This form is what you would use in the event of injury from an accident or it may be used if you have benefits that cover wellness procedures such as mammograms or pap smears. Failure to complete all sections may result in a delay in processing this claim. This form is what you would use in the event of injury from an accident or it may be used if you have benefits that cover wellness procedures such as mammograms. Aflac is not licensed to solicit business in new york, guam, puerto rico, or the virgin islands. Free download accident wellness benefit claim form pdf, 74kb and customize with our editable templates, waivers and forms for your needs. Aflac wellness claim forms printable fill online, printable, fillable. Fax this form to 18774423522 or return the form to aflac, attn. Download aflac cancer screening wellness benefit claim form. S00198ca failure to complete this form in its entirety may result in a delay in processing this claim. Please complete a separate form for each individual andor calendar year. Accident claim form failure to complete all sections may result in a delay in processing this claim. Claimantsignature familyrelationship,ifnotpolicyholder date page1of3 0708 cancer policynumber shorttermdisabilitysickness disabilityrider policynumber.
Please check tm your policy for a list of covered wellness procedures or call 180099aflac 18009923522 for. Start a free trial now to save yourself time and money. Continental american insurance company caic, a proud member of the aflac family. Sign, date, and mail or fax the completed form to the addressnumber shown below. Accident wellness benefit claim form instructions please use black or blue ink only and print legibly when completing this form in its entirety.
Do not include receipts, statements, or other documentation with this form. Forms received without signature will not be processed. Please check this box if you are filing for a wellness benefit under multiple coverages. Keep a copy of the supporting documentation and this completed form for your records. Fill out, securely sign, print or email your hospital indemnity wellness benefit claim form aflac group insurance instantly with signnow. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. Claim forms and other valuable information may be found on. Your aflac new york policy provides one wellness benefit per covered person, per calendar year, and this. You may either write a lengthy letter to make your claim, or you may fill the easy. Sign, fax and printable from pc, ipad, tablet or mobile with pdffiller. The aflac claim form is of much use when you have to claim your aflac insurance from the insurance provider. Benefits are payable to you unless we receive written authorization from your provider to assign benefits to. American family life assurance company of columbus aflac attn. Aflac accident hospital indemnity wellness benefit claim.
Your aflac policy provides one wellness benefit per covered person, per calendar. Wellness claim form if you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our customer care center at 1 8003484489 8. Aflac accident hospital indemnity wellness benefit claim form. Accident wellness benefit claim form snohomish county. Use only blue or black ink while completing this entire form. We care about aflacs policyholders affected by the recent severe weather. Critical illness health screening form failure to complete all sections may result in a delay in processing this claim.
The facts say you need the protection of the aflac accident advantage insurance policy. Accident wellness benefit claim form do not write on form except as instructed. Please sign the attached hipaa form and return it with the completed claim form. Physical therapy must be for injuries sustained in a covered accident and must start within 30 days of the covered accident or discharge from the. Under the download a claim form heading, users select a state from the dropdown menu and click submit. Failure to follow these instructions will delay the processing of your claim. Is aflacs wellness benefit claim form available online. Fill aflac wellness claim forms printable, edit online. Your aflac policy provides one wellness benefit per covered person, per calendar year, and this form is. Aflac also provides pap smear and mammogram benefits once per year.
Fill out, securely sign, print or email your aflac accident claim form instantly with signnow. Some of the tests listed may not be covered under the wellness benefit of your policy. Aflac printable claim forms esign pdf with electronic. I am able to modify the forms to fit my special needs and requirements. Accident wellness benefit claim form failure to complete all sections may result in a delay in processing this claim. To help provide relief for puerto rico policyholders affected by earthquakes, aflac will defer premium payments coming due for affected policyholders, starting december 28, 2019, and ending march 9, 2020. Incomplete forms cannot be processed and will be returned.
Do not include receipts, statements or other documentation. Aflacs wellness benefit claim form is available online by visiting, clicking on enter under the individuals and policyholders heading, and then clicking on claim forms. Pdf accidenthospital indemnity wellness benefit claim. Cancer screening wellness benefit claim form please use black or blue ink only and print legibly when completing this form in its entirety. Failure to complete this form in its entirety may result in a delay in processing this claim. American family life assurance company of columbus aflac. Life claim forms for the state of illinois must be obtained by contacting aflac worldwide headquarters at 800. Mark only wellness exam boxes for tests that you had. Free accident wellness benefit claim form pdf 74kb 2.
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