Aflac Short Term Disability Claim Form. Policyholder’s statement (forms are to be completed on or after disability date to avoid processing delays) Annual income must be $9,000 or greater for coverage to be issued.
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That means no medical questionnaire is required. Date of birth gender policy holder’s address: To be completed by aflac associate/agent. To avoid delay, all questions must be answered.) please complete both pages of this form for pregnancy disability only: Nt (forms are to be completed on or after disability date to avoid processing delays) policy holder’s name: For claim forms, visit our web site at aflac.com. Web short term disability claim form *please attach paperwork for any additional income you are receiving during this period of disability.* **please sign and return the attached authorization. Web short term disability claim form. This * denotes a required field. This is a supplement to health insurance.
Consider filing online for faster claims payment! Web for assistance or information, call 1.800.99.aflac (1.800.992.3522). My coverage here you’ll find a copy of your policy and benefit details to see what’s covered and benefit amounts. If disability, is later, determined to be for a longer term, there will be follow up forms required at that time. Web download aflac short term disability claim form, also known as aflac initial disability claim form. *last name *first name *date of birth (mm/dd/yy) / / physician information: This form is used to file a claim for short term disability. This * denotes a required field. Date of birth gender policy holder’s address: Web short term disability claim form *please attach paperwork for any additional income you are receiving during this period of disability.* **please sign and return the attached authorization. *last name suffix *first name *date of birth (mm/dd/yy) / / patient information:
