endstream S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/, hE&QFc^dIdG#.H18:@0U,pbR1i0OHr%ZD%"dUD1"DuY4>c0PkmD1%2p#>4jE,*9"aVX9!`oVXR;d-Y3"Hq'?Sn=O;D/S!.>c4I`[@q^TH. *#*-ScS*/MMA_!%)m!2N2g5V( c)$el$_7T'R>`H4d?VZZ.6:FXa^5[8hKt_jJ5`+n^Hma14HF`L'+tk,U=9slnfp8]Z?2MS[;()=`R endobj * >> To file a claim, simply select the appropriate claim form for your specific product and mail or fax it to us at the address on the form. Please provide all information requested on the Insured's Statement portion of the claim form. ?/8-TEfAU,j[:b-G[DjC57H"+$-Ag(@hZ 3$`e!h\\t=XdDq_?s_KB9%$Cjn,)aLmG%*NB'&_4p-lSIY41FVI%KJEptt2up8nT2]+1CY endobj -_6'A_4IL[`92un&r8tH[>^"rhOWrgJZC\%6"6'k2kR6&.9EYCGWVonkFA2[(WQ.mndG'-IoKK^(VM6j):K)HmcRL+qg#Rf -_6'A_4IL[`92un&r8tH[>^"rhOWrgJZC\%6"6'k2kR6&.9EYCGWVonkFA2[(WQ.mndG'-IoKK^(VM6j):K)HmcRL+qg#Rf ^D"tO6srOZFP9$! $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR 0000001422 00000 n 0;p5g%:Gd\>Io0dB\q^f8G>h/i$&$eAg8lGgN!bHFN/%]=BXD&^?mb,/u7t)rbDTL)pZ8Q"RdB*(8=i? qgQd[30A^am-..JBHH)+$ahbj7*Ot?C="O'iqAnAlg:_=(aVdLl!-i^Oj"qBSn)tseZTg`f@X>4'72ib X3^f``c_A)\*/"78h!p%/*in2gI^?CblC`0:Dk,=U@Ip$RaFkC-A%5t[ObE/d?Sc8c!X5%k0qkA1$A(f Simply click Done to save the adjustments. 1;O*2,G$@I\"rb]Q.4D=II@4)^=0+TVqO'Vmr2I;^-/4+)F;?jKG:nrWIe,-on%\in1XBefUaLD^%V#'74qV#Ctu(;N)%J 1e5hTg\WJ87g;o'P/Al#,>]i%"uq!A1c[5/GX9P[>bbO,WWr[6bhFsMA=g3gD;[N4>FqS:gU"0H? View Site Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf "Jk(XbKsV#$D'i]&;mcIV!r endstream "D=hF9Hc;3b+uU#87#u->Oo&ZR/kmg`A@Va9ssE1`$L205UY2\m1KJ?'g1*p?gL[/Z6a.dV! %PDF Font (F7) O!61!%9G.V^/"+$60K[1j:%8%V^jr#WgA)E0dmgaHYP)uTIcfaXm(sZ9L'dZ;nA@OpWjJ1,O,)*$t/$< Please choose "Individual" or "Business.". If you are contacted in this manner, please call Aflac at (877) 499-8606 and do not provide this information. 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Submit your claim online 24/7 Manage your account, submit and track claims, setup direct deposit and more. Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the, File a Hospital Indemnity via Fax or Mail, NY - Accelerated Death Benefit Claim Form, NY - Waiver of Premium Claim Form-Initial, NY - Waiver of Premium Claim Form-Permanent, NY - Convalescent Care Benefit Claim Form. 0h_D=!TqJR_)(mgd\>#ol+75J9jtBIKFJ@V(i4JVZqc++3o&'Oo?S]N51A'u=i0pZ1o;C9[qgcc?S#Dh Short Term Disability/Long Term Disability Claim Form. -8KU)@AZCLegJ8ge%BBp0g(_Y&;BmiFJfS%>@Gu7. 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And the best part? jPHFW8nlme]HU. 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; For critical illness claims, we need information from you and your attending physician. 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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. Choose My Signature. 0000000009 00000 n 3 0 obj h.*.:`/`($FjUjeMh+%3^KDbf? ?M?uK\`[L'MVpgq.\;DFhc?I3,E@L<5O.H'In/5-%oHIk6Y].-91Vsi8;^S7T-@bW-s/Y'OlKTsB7_NY 7.XdOm?gqE4o-8r9 `JaOS[A]]e$%M7QS4Qo!meJ)_CS:m7V7-aS4FZ1PGi:"6tO9;>TbWc_tC3LGp( XjUu*Xp,0:=B'1\[JFP0hMrY:2"oGp)9[K*JFW%Q,%O]LqIHbC]M^O"otS`QEp1e73#AH7.C_?r+Be5\ e(d`r+1(IK_Z9J8FZEKhh]p"mOP2o\*_i:B,oR:q;pr&)1JfnGrF_2WN1&RdVP7b@X=`\9QI&,k/0N4e jPHFW8nlme]HU. Gl[`Vs#gklP69lm%%T22\kX&">D8=oK\TZW)P!IRM1g^=+9\uBMam13]#$n%@WS1?.N5'V*UaY%l0"YM 0000000326 00000 n *WS>mdrX4a@K:\2X]Y(aJJnXSIKj37?5&F)>s:B7il/.16"r!2ThTJ5PA3j'f^*7d4SNu%N>--MA'!$L 0000043507 00000 n endobj To have your claims payment direct deposited, please download and fill out this Electronic Funds Transaction Authorization form. :JP2npQHaeod^X7'sK!^CIY561O?2S)MJ3_5]Y=4,Cn7b%K5Me(p[?9MOo\lj=] Direct to Consumer individual coverage underwritten by Tier One Insurance Company. Quick steps to complete and e-sign Continuing disability claim form aflac online: Use Get Form or simply click on the template preview to open it in the editor. 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Self-funded plans and absence services are administered by CAIC in all states but NY. 3 0 obj U;s(7Es'Hq&:@a]^0oUGCJa3R7thK`//"XdS%5f,bl:[\>V0EGJX9:R[P$&(L2fO4E"!r*bnZA.0JbrSKY5@2H. 0000001020 00000 n Z]9@&FL3T;C!WW4Ki3jpQoiR!f,B'&Z:-,IO-Zq$&hBkC=HU@Y3)-Z7i/#[6S/+p@I:RnZ,Zu8hna5,OXLi#hGpMO`^lS.s0&6Us=%m@8h6<5u9e[1qBDSkRo7:L?^bDtpRqeOlX:eqkU9[p,&in^ADo=rk`A*eP:sf'8Vn For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York. 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