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[:'^X endobj 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). 0000000009 00000 n GI<4I]m0"m@3FYSQ)X4mH$"lpr?SS"XrqNZgPRAN%fu;@WUi\JB1C[?[B?. $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K <>stream endobj FXd-mhfj\dS((^`0K6!.q%j)EYH;^Rd.Aa`hf%gahFK:H:&//7pMV3D2qV#r4Oea\q/upjBMGec[O,Y:5n_u^Q$*P(4j$+WU5q!\lQS0:!H;gK DE.V"?h'jom'g4taZ=ggb[Rq9*%"D3_?>DBHcG"%EYhs\A)[02C%,[#:eC])1_\$c?cV\_3\d).P:QmEm*p#YH<04bhGCYr_BRigd-lMFY&qm3!U7+E'.29BdD[1$Xoi)[=&jM/3ntoZ9Yk9SnM:+ m^PaP#$T,QfVQ'7kTb=#ja*O^[oT:q1qW?WH%a_Lp. xref For disability claims, we will need information from you, from your employer, and from your attending physician. nhH(@HB3(k..$A&2I&hNumCF[&]PjI*`R_D2M6]X>#-E#f;915&(PF6%>9Knd"E.:PO HQ$ujRc"9@)AC83@/u';(.AU@8h[,dM5@MBi91i8@]+f5P8hFJ11.%Ec:Brs4lZA';_labWMQK7-EQHe In CA, CAIC does business as Continental American Life Insurance Company (CAIC NAIC 71730) 8*C9[J(Cl:;Gi9qfiditHQ#'L]jC2sPgd`'`W#[3J"LQg0%?W3t_5VRgmCJ5=M#ORRY\sAH6Rq;5+ChV$?jn,^o9SGo>Ha 0000055102 00000 n #DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! 29Q-bd"lOXj_`+YYr:EA4 If you have already had your physician complete and return this form, simply select "File Online" below and follow the instructions. 6,k1;gaBDk.XY%J:F9As.#C&J>pqd^X_`2(g"7EVNm@*ELI1%cI ]Ic'l[Ucs$aC(lNOL3_Hu70AR(nl%uh/8Mpt4L2j*61I9N5(i,IR;G@j;#["p&LU,X>BR_AYKK6.R/dNK"(^)?d.HOT8Opb0Y-K\%)C64ibd!\^el)-+>j:\a[jWR6/W"V7$&<2ChQ4GQ3m]%-]eU36,7(7&j^8g0t0._o5#)MF+=O0%0JZsOU541%";UhbOU541$qhQCX^U/X4>K3,D$=_4r%W\&S\MZi0BE\KZCLf\GR)(H"TPAbB>9a5R_bAOr9WH[a\MZ.8'b&$<8)CZC!4q/$KA=egJk37Y-1E[86[%\Q8F@Ib#lC'QaPAJ_!-i/?KdVG"X#_=\516`^^\5J,M/.DIa\*YoK("Ilc7:\Z!R!s#oBE\L=Mo^G"0[nG`5V"#mcLGq-fm(][p0CmKXlc98[>OE;Z/7+o2eE!LDjPa!a3Xc:0DZRWnntJY5N;J?0eM/NN[?FDc1*_BD4,fH?NW^RLYY)!s0cFkh7TIbZO^6D,e>Dc*8`HqDdK^f5,@XY;DpFtX]=7B\)[5Tnfu-3$sRuHF:Yh5'IV`6%-m4Y.bOGfjZ)(qBXT;C[`r?0DD5;2)a8.>B\E]#K4+#M?QZ,2jt>l2-a^eJUVSD!$n^V+2KS`Z(&b7f>D\c[,cbDnI4RtYNNY'\j^e:/MTc%[.&Mi>Z89csFkO_me;R=pA8XQ.='6KHrksNkk*r9FX=S4Pgr\U>)LU5Z,0PIFd?h1K=.dmASs68D`.HQBQ8=FLf"fMskfFj8:[Dn597>tbl?nmbEA5SDre>S,3Deg@^FLUSDBA)p%)5RIVgXbP`on^-X@s(>%\g1:1g-Ajr[lATDl@UCM[dLm)1Q1+HU#b])Erj(I@+9m#p4k5]ncg6)T6;E!O;b->F7sSX?aRu-P@hC&7M%b&g/\9Yd'&gar3\#MN%b[$3Y2%,([$$!Sb:YTWCG]j2+aG"2aZ-"`S]Al;)59HFIu;io(nY/H9B@6iFQi3XdcW9Z-V6BgCIF"eCT9P\"M`BQi15C1'7&VWI5c1I.s(>fq'HRp]Cb$Rqk,?C+Y'I/&mA*)/fjc@on>V1EDFR>i9ni(>e6,gV6[.`lEk#T#^0>n4cs+"I$9AbNd6MMHmgP(.+9DS]%Au*>#2LX^T9h_]SOMI20Cj1M&?NqGF(B;h9Cqf?G2iM0gOD]RR;E$7UJHl(Vc3,?YgX1JCUp$h)/n="5=st8J,~> 0000000446 00000 n ;]2"WH3RN-IY-eA348fl;R6]T4%O*^emkHfI8Di4T'&!Ns\94;%b Beneficiary's Statement for Death Claim Form. You will be automatically redirected in 10 seconds or click the button below to be redirected immediately. In NY both group and individual coverage is offered by American Family Life Assurance Company of New York. Bk\1f/VUX4ST4NT40lN34+-*[pI_iW#ggd2*`hgWE^=-R:s=)2'tu01Vr]^_S>-&.RS7)o+'X@(Y83/( 26 0 obj /I1 14 0 R /P0 15 0 R /P1 16 0 R /P2 17 0 R And the best part? endstream 0;p5g%:Gd\>Io0dB\q^f8G>h/i$&$eAg8lGgN!bHFN/%]=BXD&^?mb,/u7t)rbDTL)pZ8Q"RdB*(8=i? -_6'A_4IL[`92un&r8tH[>^"rhOWrgJZC\%6"6'k2kR6&.9EYCGWVonkFA2[(WQ.mndG'-IoKK^(VM6j):K)HmcRL+qg#Rf 0000003079 00000 n *WS>mdrX4a@K:\2X]Y(aJJnXSIKj37?5&F)>s:B7il/.16"r!2ThTJ5PA3j'f^*7d4SNu%N>--MA'!$L FXd-mhfj\dS((^`0K6!.q%j)EYH;^Rd.Aa`hf%gahFK:H:&//7pMV3D2qV#r4Oea\q/upjBMGec[O,Y:5n_u^Q$*P(4j$+WU5q!\lQS0:!H;gK 8,Y5:-bZ-;Z%c':c]*),@W=_c. 0h_D=!TqJR_)(mgd\>#ol+75J9jtBIKFJ@V(i4JVZqc++3o&'Oo?S]N51A'u=i0pZ1o;C9[qgcc?S#Dh 22 0 obj )lM~> /ToUnicode 13 0 R 3TjKSEQ8:S+XUe3iJa"79`?s5c,-YU]aQt>=/Q\K4ePWk8tUHMNos%)gp)1M'YH]uh'HQ!l(m'P9e66@:#UA1$A@flpm %%EOF, ^#$J_1B!E\jQnDo*AZEPW#Q5HmqO\,o&d+LqKX0];I^YQ!dK5/)RRb8kQ;c1SD&I_aWfY7X jd*ZcXe"_QS4SaSM0H8\:kGm7EGchf:.,NK]?.0?7FYh&?aae5>4\THpn]0*9A8N << /Count 1 /First 18 0 R /Last 18 0 R >> endstream FXd-mhfj\dS((^`0K6!.q%j)EYH;^Rd.Aa`hf%gahFK:H:&//7pMV3D2qV#r4Oea\q/upjBMGec[O,Y:5n_u^Q$*P(4j$+WU5q!\lQS0:!H;gK $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K IsNhEk,PeVb^BZe[*I4rabcN&lDZ'ULHK+-T$;u]WD3GH('p*58J'[(3mgr(:*0TR2iG4M503dao>uU! startxref cC5a$qEUFt(E8e->F3f^Yr:J8cr+o+V8SWC.sUDP!9a:YTD`h-6Dlku'HCEL>"u[SakEau qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib <> endobj "\1ceiPob[!+@J3(3TJ)YX)OUj[W9&;I:dYZ=kc)4eebY'g`kA>>[&O][obn/UEdfgRXrat28;.HM:HQa#NGoYVo#="o%! 0000001020 00000 n 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. 0000043584 00000 n Dental and Vision plans are administered by Aflac Benefit Solutions, Inc. 0000040092 00000 n 16 0 obj Apply to Behavior Technician, Para Educator, Family Service Counselor and more! endobj For Sale - 1420 W 1700 N, Provo, UT - $599,000. endstream <> "iE5=j8``/gXCMXF <> Aflac Short-Term Disability Insurance pays cash benefits for covered disabilities (subject to exclusions and limitations). ;$R8>sZ"E&^#$J_1B!E\jQnDo*AZEPW#Q5HmqO\,o&d+LqKX0];I^YQ!dK5/)RRb8kQ;c1SD&I_aWfY7X 20 0 obj ^D"tO6srOZFP9$! 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). )toiFe(5W*JmS'IeRpMhRM\E^RfC)>n7:/sPgsY5E^.`.P>\/9SK;2 Aflac, excluding psychotherapy notes, and including, but not limited to, . >> 2"3sWA960?8;mmK#ZE2_=#C>QJ%q+@gg/`.\j'lY3GBQ_ecS2/`]F/b3$3maOCefRcJ`5!g@1,GaV\/9 T9khijaBNZR9C,%t"7Fg@HCRo`)?gN`jH7$+&;F&1h$f-gZ@qpFS8g[qONg*?3muhSPi%q01m@ 01Kfu^/nVO+L(Jdq73kWrp8S-B^0`qh,U[o.OS(9*S//rm]sB[#0$Ikq. 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Enter all required information in the necessary fillable fields. Fill out all of the required fields (these are yellow-colored). >> 17 0 obj c)$el$_7T'R>`H4d?VZZ.6:FXa^5[8hKt_jJ5`+n^Hma14HF`L'+tk,U=9slnfp8]Z?2MS[;()=`R =[GYSI.i$`\)6Yek?R3(hf\K7.q'`4X>.c*a*j"/k@0B+Aq? 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IgeDH7TM\#pU10L#Ss`6=>>>RJf3(u"SS*/4)kIZjBeggFpXisbnT"]8aV=2.gG!O"):K$0*DuMhDAGnARk37 c5lMh,QXUsVpDOgY[E488MHV?GK9DUk^qXiSo6?d"#T=f:;YTi0SU1_S\M2I.26bpPB\Xsl"fN>oQoH- 0000030858 00000 n ::bl''..9BC;a\$BlT\:t-X,fsW*QN`2e(KL AkJD?1M>up>BcsX+I=_#LC$k%qGLcEUfd4i%!i& Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the Pre-Existing Investigation Statement. #18R:]\1;,nqN5j4@OmooAng>Dj7\$6I5WEl9T2tR'\SuV`NS+%%o_@bX'RnWu4:b)*k#n1R(+?O9$>r CONTINENTAL AMERICAN INSURANCE COMPANY Post Office Box 84075 * Columbus, GA. 31993 Phone (800) 4333036 * - Fax (866) 849-2970 SHORT TERM DISABILITY CLAIM FORM *Please attach paperwork for any additional income you are receiving during this period of disability. T9khijaBNZR9C,%t"7Fg@HCRo`)?gN`jH7$+&;F&1h$f-gZ@qpFS8g[qONg*?3muhSPi%q01m@ <> /XObject << )O:TmS'Yten(!-m^G>i5()8T=P8W`gZb#8cl/H/? 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Submit your claim online 24/7 Manage your account, submit and track claims, setup direct deposit and more. ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; -8KU)@AZCLegJ8ge%BBp0g(_Y&;BmiFJfS%>@Gu7. endobj 0000049332 00000 n endobj (8p@RL@:%uhr=mo1Fg6rg/M;<4* \&)R4M>ms@. 2&Tk-bp^c+fLgI$.,d5^! <> No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/ai^g,u(4jLe=m[4V59--p2Tap(*UC^8Qur;jVC%5c7VaBB+,0AUKH@dUPF5MD Please complete the Patient section, Boxes 818, as well as the Policyholder/Employee section (excluding Boxes 3138 and 40.) 'L_g'N&-hd[;0t$*n/>649o==0mM=iT3\5)+p[n+X5`?CY@j.i4h`gXCf+nfk(n(Oi3le.$J">(K1Vhh endobj ;:9bBtb9H]qk\bkhPfIu$"+1TVJFo3OYhdrtnn;;,mTF]?KG*]5oEoE,[rmic= Simply select "File Online" below and follow the instructions. 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State-paid family leave View more Life insurance View more Long-term disability insurance View more Short-term disability insurance View more Leave of absence View more Contact us endstream )_uYFAPMnh@@qLR(!tj0,JgDV:^2aU1j,Q1G5%+A&.^pn]C"PJA:oAllMYj0psPAVZ_E,8iGS^\I&;A'/E"CXIR`WpK_.^,?uB7C2c/q!Ft;r%bq\)j#XX/c~> ;dps@dXdX$3sN65dLrqK;34,XZ>#G6k1;= endstream Individual Policies: For step-by-step tutorials on filing an online claim, please see our claims checklists. !ncB:\VKdEm`qT:*N=[JNN2d(=N=eQCP0@YV._+qhu3A\"7SbVdlGbB#r@F8W,NFT7X_+Li_!4M/4=!o k0Q'9K%4rkrrN3]cu8p8';m8q-eHY2Sa?q0DqdO_]i_5()gWNP#-%H8k&XV=Id,j>)pb@S-4-ot]OZm4 endobj /BaseFont /ZapfDingbats << /Count 1 /First 18 0 R /Last 18 0 R >> oJ!qE004N-XBk;7k]qo&bs<9Pm9 endstream If your certificate number issued to you is in a numerical value, Example: 1234567891, please only use the two forms below. T9khijaBNZR9C,%t"7Fg@HCRo`)?gN`jH7$+&;F&1h$f-gZ@qpFS8g[qONg*?3muhSPi%q01m@ [:'^X xref InitialDisabilityChecklist Isdisabilityduetoasickness? 0000054624 00000 n /I1 14 0 R /P0 15 0 R /P1 16 0 R /P2 17 0 R Payments can be used as needed - to help with medical bills, recovery expenses or even to help you pay for rent or groceries. endobj /Subtype /Type1 XL9IY_,^5e)u%m(QSW8`,Ms+JJ"IKSqK)]ClhR1"S67]3AnXNZbU5t!S#5jg;<=EaA8%\YmR9]u3\kc^ And the best part? ;dps@dXdX$3sN65dLrqK;34,XZ>#G6k1;= <>stream Online Claim Form Aflac https://www.aflac.com/file-a-claim/default.aspx When you use MyAflac filing your claim online is an easy way to get paid fast. 0000049255 00000 n *Before filing a critical illness claim online, please ask your physician to complete and return the Physician's Statement Form*. <>stream 0000001422 00000 n <> (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!AicdVn^"gp(^-oKqo#i"gBOsIn1fK.\PJgLt&^imq7BSJ..gu`g3TNp]lZQ:Q+PSQZ=7bSOhN`;B#7;s#7r)aO+XB?-BFdCkA(+.VnQp*5O$?iSK/`O.QJ'S)/aPDmhO:I1AIuZ^Ves%d@6'UQ5gRhf3BF`kXpaej\IRil\Y_Tp',^\5b3DiW.2X/9G,ZBZNQ1%0jnNTP=-/t4]pG5O*!$Hj%$(Vi!33gU7QS]rt"S4I%1~> ,-TQAaYC[5-ru"XbG^9qf`7Q_V*TD8eW0!d4tTL2](RU^lH!V+k6L3^9)d)_:\E 1;O*2,G$@I\"rb]Q.4D=II@4)^=0+TVqO'Vmr2I;^-/4+)F;?jKG:nrWIe,-on%\in1XBefUaLD^%V#'74qV#Ctu(;N)%J )lM~> 15THsJWlVj?FW\)knqP*Lk! >> IulVik4tYO+5Y]5dC6+if#]pW>?S#%PB"2$kEPR@U_!W)J++r5@@21spCE@V_m\2SM=jcqaH.-P9&U%f [u"0oO\5'j_^6BobJWi[hgme'ak6Kf@+ /Encoding 4 0 R endobj 0;p5g%:Gd\>Io0dB\q^f8G>h/i$&$eAg8lGgN!bHFN/%]=BXD&^?mb,/u7t)rbDTL)pZ8Q"RdB*(8=i? 5]mS)I&\m'[NsCj]sr@0El\`]Uq+.S367pgfd2I2(=P['dU+EV"7XqK'c7K%if?fQ]VP This form may be used on all product claims except Group Term Life, Group Whole Life and AD&D claims. Aflac Group | Columbia, SC /Title (New Claim Form PDFs for WEB - S00224) 0000049255 00000 n All forms are printable and downloadable. V5bB]IKpbaW#Pkc)(CZgno17ikI&QH)d'BE1WU?WT View details, map and photos of this duplex property with 4 bedrooms and 2 total baths. 26 0 obj :0&HC(d$*r1.Y<=jD`$Ia7bVR3*X"Pd8ODQ(-pM4B8oHgR 0000000212 00000 n 20 0 obj