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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). 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). 8*C9[J(Cl:;Gi9qfiditHQ#'L]jC2sPgd`'`W#[3J"LQg0%?W3t_5VRgmCJ5=M#ORRY\sAH6Rq;5+ChV$?jn,^o9SGo>Ha
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There are three variants; a typed, drawn or uploaded signature. 0000000446 00000 n Please provide all the information requested in Part A of the initial claim form. Gb"/,D/UE'&cO9g'Le5&-SP5UG1U(.gN&eaNpA_5Jen>pld`Ep3L8bprUnu0/pTC:L6'E&Oj6GD1q3j9aEcrf34m?(SYF9tiIC:9reE'%4hLa2A@q$X^Gul'8"j\_Z*Pnco=On_l;2u]$YT1JT1XNYZ$TWMcEU?(Ui>2@/K'qS2q=(qBpq<3n9RGEE0_8LAA>/$)9CPnE%+9ApaZ,q%!Z@U^=:+[a/uKS+%k1MN.5&^;J?&K;ie$ki31!T(>`p4Q/r^7M/gh:/g6\RiOpi02X8?9HDKNojiqH\fTkO*reW@;YqPcC9h-__*61?X3pEIK=-:Mg`CsmZsnd)H'+=n"uJWaI(c]kOWO`2UbM90f_0;rj"kWn=h4\6e+LchC?K(aad&A+d=lL_&TFbfmX0*Jd>>Lmhg']bd[,I"5X<0AA:^98ST=TL-W*EXj/?&T;_5X\sh.,]!.A7hkAL;K9,acI9;+t&)dF!#U9p7>)1ab(?k%('sei:-fSqGn8$875]6O?=iNSbFZPYbpfpi\fF=d!TWfO9_A*9i`E)g2nb9[]r6;B*+jn@3B*E8a.o&10@UPpd.#Fim\Qt3S_6srHr(cgA(HP-!=E1fm'jAS%[WEUY45$jA:1*!"_h4>,'ed0`:"U?a%>q5Sk8O%L5/-VbJOt%f[Wo5&+7ZWm)`Q\MtViQg@s#N?!#?+?55mL6n4[sHFW/%Oik>,,Q49TgBiiV=`lNki3%%cN37#n.#\jo&]u\b'SQXMkff2Z+:=E__ba,4,fbGl/%NfT1%mTOhR@Hp$eX`Q]NApHg(O!T!T,JX>YrfSc*XWe,tK-f@fjb!:P5SWnUq[raVb_pulJ5eg_;UrRuPp?]KMK'N[_*8]%m5lE/MnE-j/@_"piL`o$2b!5KmcMpl\QuKQe6cFt3d"QU/8VhMg61_(pFa[DgRo[/kl'*[iUgQtmpPAY@e=1ORRB\T@Y&ni:rb-NZ2i]/;Pbn)Ua2u6L(qd)ks=?'-P66*a*#!,#`\V:ShknH6?EG@*f;6o,.]tj+)KVD%`C'e%R(78-Y!,'>d7S46qeQgD:X.>@?&V#IDL,ZUABl.bFR0(2V)lAN)QF^Y:VNJGr,<0^9+mg(4kS?=%M/O;&RHQR.kY_:0U+3UiT0l;08h3,bP>Tsj5U^SoN_Cou8K3moS,"K9`Z`;s5*o9lCWSLVQ2bfj&klQ409JYQ.(1Jl'B%@9$i@pmb)GV`ANI^.?,OrNXq7rn!RPR*pKnG0";)$hnRY3Na_+4eo`l*Rf[7V7$BT;Hq&6m\*m^I>!#d$>&;?T+`ccsgY1q0]B[PIc;."8N4h08/D5'K7A*nV2KdGFWT"^SSIs:V1$^@,MDm-V,+oO6JtnX^/m[cEq`!?rH3`YI0cmWR"8g$/C/.+P\:)5[8jO$t!d\KSmXNOEr%:bg*AT5!?I0h75@nQ5rO)*(jd=kNcAd7$W=#YU)gJ_)^\D]!duA4Y#&>q6Wh!_O+IiRBMqDTm9H"-I'2m"XKZPJq?9=O95Od2JW(,0eXenP6H2L3)sWB\,I1e$uGg%):=Zg9it2S=Qa%FBIWcqqI$?UN5n=LFCbrrPG=QD4*5Zh.r,t?fL@e+`WG8)KnFiMJqn>N2aW.H/Rc*'uj0Ln97(H.aF2tMHd1M/o9KXDQHF9/UT9&QIUTI5Z82l?!=7]TLuX?-^'Ff"b^Z]e9-nn8_nN1:>j@91NTeBp%-W*,UW'0;Zs+%MsoCUq__]ahrQ_?>IQtA07A:.r4XV,T,mLf]ShS4914P3kYD^)KhQ:[^>JVT?pg*\ktXteM3K3s*[#Xa(ZV&cjs1Top:ClIhp]a[qR%]G^Xg)-Y?Sn.p8p=9Qk>UhQ6`jRmo3_uY(Q9Ma%Q'r/PbX`Wka@$F@Iut5SCH[:e%)nl;j]Ta@fK%i=_M>uWQ'2@?H;h8ar*=UOR,2o`fQu@+QH)K-piLh/a-J"&>^@kT996'GcZ1(8.2(tkUlu^Gupc7)bEOcBTBm"XLiL\0!$>_J7/I2=;%P5VulZgVP91SIms>4HT;9\Y5a_hi]denkL19?h/]=3eF=hVhIbn/++t$3W6].KQgAH_#eOk#HA7ZDGm>D'=T0pGhAA&F#'9L9GAB6!^R6WI!_BNY0Yg-kl%&U,+ic[XbJ)8hqNnKJ>-a`4LS>d^+JE>lKa#%)Xu?13'+ca'WIEAOd?Y6$MtOP1K``[PW*!2n[$qQI3]OSB^[OfBB!ijns;OJk#L^/:e0XaG+cKJ>&dt_VCu9jE^Kf?`Rt$Q^WKJI7c?2#D%4&i"5BA,\DhaPFbfHO&Y(E]r/[[6VNDn9*o+7*TbdQVpTNJP.4pbT=%Rf:]dN6bM+&god8d+B1,J;UNK-WBi)#Zuk8Hid\*WHp^BUXt$&_e"h%rWCICP'/ABL#24>X/e"*0oIS%1e)_V1%n.[J:%9?t/!G'Ti],DoOCBF]CA)YH+:,b.s(t1a)=hr]j8(f@EM;/b7l6(ai4c#LGHkL$o071#7)J9GY4gTVr#:'T=*QD_kt=`&9Cq_=Xd,Nke/#%!)34-M[ro998>9bnD/N>iqjE_\p0*BsnqTkiK_`6'DA?s.n7P3k)JPSQZG4D'G%h?8?%%HP@tr"8;u*u@73kB6`*9^G&jQ#K>MGcB5cQlXdqS^NjY3Id)%u/Sd5s^gcP&tT[f&Gn""Y^):oK,/\:NdSg@JJ?bRD7(3aKua`XgV;VRMfo2Ys9rhoL85bT%##/ff'Xl`^[P$5JLicJnrEsLEZ^]WLhGAXBOG3gc&1TR(CI]Ca2"In8:G)T)"VR(2!cO_.44"pNn$R>Zo"aD2\A*;KDHn/%A^Djt+U*T3?U=(9%UbRZ!L8E)t!"Q6+]#6^gmNh;-"l=lJRiRpdU:\_\\Ia=)Q6)V18ar)8JCkGq@N@3n*jg^&t_18^[Td/g^(=b)9.EXV/PU!nl,@SVbf[=QO0E4RVKB4.dh_cT;'?(l@*@Y`rN=H*e1/+7u]a,s#ITK7eqBO"[J0KCfX!mWFh6f0qf-pE]N5DCsG8I5<8WSngn$-cT-W^YT38)gM?-rCP^'-r0`Y&tsg_ncDO:%EN+k7;rH1j!k*2k!VrJrWEbHQQ?.%ajJ#`H!O7gE4I9_h>$Ai7O@>O;%0-$BNcRrmtbUb:u+Xb^g7:Y^bZp$i[K#[M;p_))3%#VZCou%b9;UBi>.srIrE3#D.'KLV$nt%#Wq6k)$U(b$o%5]TAbfR;9cgi#WVmE,aj8rTSdC.OGL1fCjOiC?d#HNPE<>gnjZnRrET1FM5h/Euj(#f9d")3O2'YqId"-U:*".(^\q101NEm#WAO5? 8*C9[J(Cl:;Gi9qfiditHQ#'L]jC2sPgd`'`W#[3J"LQg0%?W3t_5VRgmCJ5=M#ORRY\sAH6Rq;5+ChV$?jn,^o9SGo>Ha
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0000000326 00000 n Please include all dates of treatment and charges incurred due to the accident. 0000049255 00000 n #DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! 0000001020 00000 n Follow our simple actions to get your Aflac Continuing Disability Form ready rapidly: Pick the template from the library. 23 0 obj Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r
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View details, map and photos of this single family property with 5 bedrooms and 3 total baths. R5BsS,N[X$9*1Su`V5!FLu53L/`5$Sl[7rqO,!^]g&GFP&S?ljI>6jN,bnDr8aF$lN\@CTOcGe"W!E$o
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16 0 obj Had your Employer complete the Employer's Statement, and had it returned to you? ];]KtG'T^mQ6k\65n-CO3CpUj:9mE5T+QAa^Vn$W>6ZWQM=\_oAF,SBqE
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0000000446 00000 n >> ?f48_G,BN0p=/>&*)"gUTVU[Y>F[!H0S$cH]UJRYpFnh6'Ae"7a6i,,,Lbtk3(JMM]r0XUgZr>L@0I'i
23 0 obj A hospital indemnity claim requires supporting documentation for review of benefits, itemized bills showing medical treatment dates and diagnosed conditions, hospital admission and discharge papers for inpatient hospital admission and confinement benefits, pharmacy receipts for prescription drug reimbursement, and a signed and dated Authorization for Disclosure of Health Information (HIPAA form). QQZnEET3`^=L@5Inq5fkUd?/3Y2`;02=IqDob^'R&m,FG.6*VIW,-bt2>#UYOZJj>;fU1^9uM()U8*1b
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Short Term Disability Claim Form Instructions Aflac https://www.aflacgroupinsurance.com/docs/customer-service/claim-forms/group-disability-claims/disabilityclaimform.pdf Note: This form is for initial filing of a disability claim. 0JTM8HGN-uYUmTOelVf]F4AA)ZISHh>(!HVXe#12]a#X:Z;?uk$a0t'3>1o_N(G1e9TB>Kme4`U:>O6e
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