Please use black or blue ink only and print legibly when completing this form in its entirety. Please check this box if you are filing for a wellness benefit under multiple coverages. Claim forms and other valuable information may be found on. The way to complete the online aflac claim forms on the internet. Accident wellness benefit claim form failure to complete all sections may result in a delay in processing this claim. When you use aflac smartclaim to submit accident, cancer, hospitalization or illness claims online youll get paid fast.
Some of the tests listed may not be covered under the wellness benefit of your policy. Hospital indemnity plan wellness benefit claim form do not write on form except as instructed. Aflac claims appeals, po box 84065, columbus, ga 319089998 please use the claim appeal form to organize your request. I am able to modify the forms to fit my special needs and requirements. The advanced tools of the editor will direct you through the editable pdf template.
Your aflac policy provides one wellness benefit per covered person, per calendar year, and this form is designed specifically for this benefit. Do not include receipts, statements or other documentation. Please note that these benefits are not payable for treatment within the first 12 months of the policys effective date. 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. Cancer screening wellness benefit claim form please use black or blue ink only and print legibly when completing this form in its entirety.
If you disagree with a claims decision, you may submit an appeal, citing supporting policy provisions. Aflac accident hospital indemnity wellness benefit claim. Claimantsignature familyrelationship,ifnotpolicyholder date page1of3 0708 cancer policynumber shorttermdisabilitysickness disabilityrider policynumber. Accident wellness benefit claim form some of the tests listed may not be covered under the wellness benefit of your policy.
The aflac claim form is a form deigned to use when you are going to claim your aflac insurance. During these trying times, aflac wont let social distancing prevent you from getting paid. Aflac also provides pap smear and mammogram benefits once per year. Accident wellness benefit claim form snohomish county. You could suffer an accidental injury while you are working around the house or walking into work. 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. Request for cancellation of policycertificate aflac login. Enter your official identification and contact details. Pdf accidenthospital indemnity wellness benefit claim.
Wellness and health screening claim form failure to. American family life assurance company of columbus aflac attention. Failure to complete all sections may result in delayed processing of this claim. Please sign the attached hipaa form and return it with the completed claim form. Be prepared for lifes unexpected mishaps accidents can happen at any time.
Use only blue or black ink while completing this entire form. Register and login to myaflac to file a claim in your time of need. Claims for all other benefits covered under your policy must be filed separately using the appropriate claim form. Mark only wellness exam boxes for tests andor treatments received. Accident claim form failure to complete all sections may result in a delay in processing this claim. Accidenthospital indemnity wellness benefit claim form. Your aflac policy provides one wellness benefit per policy year. 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. Is aflacs wellness benefit claim form available online. 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. Ny0784 american family life assurance company of new york aflac new york ny0784. The way to complete the online aflac accident hospital indemnity wellness benefit claim form on the internet. If you are interested in filing your claim online, register using smartclaim. American family life assurance company of columbus aflac.
Download aflac cancer screening wellness benefit claim form. Continental americ an insurance company 1600 williams st columbia, south carolina 29201 18004333036 tollfree 18668492970 fax. Do not include receipts, statements or other documentation with this form. Claims department, 1932 wynnton road, columbus, ga, 31999. Hence, the form is also a lengthy one, and contains many fields to accumulate all necessary details. Please date and sign all required forms where indicated. Please be sure to explain why you disagree with aflac s decision, and include any additional supporting documentation. To receive your wellness benefit, complete the form by following the instructions. Please complete a separate form for each individual andor calendar year. Register and login below to file an aflac smartclaim.
Simply select file online below and follow the instructions. For groups sitused in new york, coverage is underwritten by american family life assurance company of new york. To prevent delays, please provide documentation from your healthcare provider to support this claim. Mark only wellness exam boxes for tests that you had performed. Incomplete forms cannot be processed and will be returned. Keep a copy of the supporting documentation and this completed form for your records. Aflac is not licensed to solicit business in new york, guam, puerto rico, or the virgin islands. Claims department worldwide headquarters 1932 wynnton road columbus, ga 31999 for information or help filing your claim, please call tollfree 180099 aflac 18009923522 or visit our web site at aflac. Please fully complete the claim form for the wellness benefit. Fax this form to 18774423522 or return the form to aflac, attn.
Please check tm your policy for a list of covered wellness procedures or call 180099 aflac 18009923522 for a wellness form specifically tailored for your policy. Your aflac new york policy provides one wellness benefit per covered person, per calendar year, and this. Aflac herein means american family life assurance company of columbus. Critical illness wellness benefit claim form instructions please use black or blue ink only and print legibly when completing this form in its entirety. Download aflac accident wellness benefit claim form pdf. Sign, date, and mail or fax the completed form to the addressnumber shown below. Do not include receipts, statements, or other documentation with this form. Users select a wellness benefit claim form from the available choices, and click on the corresponding link to download the document. Please check your policy for a list of covered wellness procedures or call 180099 aflac 18009923522 for a wellness form specifically tailored for your policy. Or your child may get injured at basketball practice.
Claims department, worldwide headquarters, 1932 wynnton road, columbus, ga 31999, as soon as possible in order to expedite claim. Cancer screening wellness benefit claim form some of the tests listed may not be covered under the wellness benefit of your policy. Claiming insurance is a much descriptive task, where you have to describe many details about your disease, disability, illness or accident etc. Your aflac policy provides one wellness benefit per covered person, per calendar year, and this form is. Watch this stepbystep video to see how to file a claim online.