;An6Y?l:#h=mlN1\Er No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . 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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). Form # 1015 Disability Claim Filing Instructions Have you 1. 13 0 obj [:'^X $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR If you are filing for disability, please complete the Initial Disability Claim Form (S00224). endobj :mWZojRr@ZVSY:Chrj]K$+%1kYl-LbN@(bf_KEb@@>[qFlJ*LgO_kj'#$nA/j,nt <>stream 0 27 endobj @lR;bed"/KM4=.N)6,FfJ&AfVrJm-US 15 0 obj Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the Pre-Existing Investigation Statement. c)$el$_7T'R>`H4d?VZZ.6:FXa^5[8hKt_jJ5`+n^Hma14HF`L'+tk,U=9slnfp8]Z?2MS[;()=`R >> %PDF Font (F2) Click the Get form key to open it and start editing. << Aflac is here to help. 2@Aq[=+(TD3oRc#`>K/0ZNjU%/:30? 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endobj ]/:~> 24 0 obj ::bl''..9BC;a\$BlT\:t-X,fsW*QN`2e(KL startxref startxref 0000054624 00000 n Aflac Group Disability Claim Form_2020. <> /Type /Font TNMF9_Vr2,SFTeXfUSJa)jt-'"mb39a6fe"7:L*nQB6WHc=tGuKXhdlF@JojFLBR3CIdNL;Gs\omg&R3 <> #uY.o`Vd[Bd.YT[///3UJY[r*;n,NhjZnQjdJ7=`r$)Ri)3:i(@X2#3?N.HcWa:.*$kP? ["`,abhS3LE"C=T6]&k%"Zl4BdN^JG3F!Y*CQe"Xqj- %+7qEQTFU"'i_\(/=gq+JNS@%Y-$pZB>:Y4*(rCZfQj@Kgqq^GWEccM#up\R$:Ie]Cf@mqFQ&(pWqBMr 0000030858 00000 n endobj endobj endobj )qT)jZA=U\YiCp>=mtH$[\__]9X3fUD/SEtnbat` 0000035380 00000 n endobj Get rid of the routine and create paperwork on the web! 0000001422 00000 n Dental and Vision plans are administered by Aflac Benefit Solutions, Inc. 0000035380 00000 n Read, signed and dated the Authorization for Release of Information? aflac continuing disability claim form Summary of Benefits for Benefits Eligible Employees Mar 31, 2022 Employees are covered by long-term disability insurance, beginning on the first day of employment. S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/ai^g,u(4jLe=m[4V59--p2Tap(*UC^8Qur;jVC%5c7VaBB+,0AUKH@dUPF5MD ;:9bBtb9H]qk\bkhPfIu$"+1TVJFo3OYhdrtnn;;,mTF]?KG*]5oEoE,[rmic= 15 0 obj Distribute immediately to the recipient. 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