Aflac Wellness Claim Forms
• Incomplete forms cannot be processedandwillbe returned. ... • Mark only wellness exambox (es) ... Failure to follow the seinstructionswilldelaytheprocessingofyour claim.
Do not include receipts, statements or other documentation with this form. Your Aflacpolicy provides one Wellness Benefit per policy year. Please note that these benefits are not payable for treatment within the first 12 months of the policy'seffectivedate.
• Incomplete forms cannot be processed and will be returned. ... Z06197AD FL American Family Life Assurance Company of Columbus (Aflac) ... _____ _____ _____ POLICYHOLDER SIGNATURE DATE ACCIDENT WELLNESS BENEFIT CLAIM FORM Flexible sigmoidoscopy Dental exam DUCK Mammogram Date: Any ...
Do not include receipts, statements, or other documentation with this form. • Do not write on the form except as instructed. • Incomplete forms cannot be processed and will be returned.
forms. Claims for all other ... using the Cancer Claim Form. If any of your wellness tests resulted in a diagnosis of cancer, ... American Family Life Assurance Company ofNewYork (Aflac NewYork)
... Enrollment / Cancellation / Change Visit the AFLAC website The following AFLAC forms are available ... Due to Sickness or Pregnancy • Continuing Disability Form • Cancer Claim Form • Physician's Visit Benefit Claim Form • AFLAC Cancellation Form ... cancer screening wellness and much ...
Aflac Benefit Services Claim Form 2. Dependent Care List each receipt separately. Use additional forms if necessary. Use the provider's certification space below only if no receipt is attached.
CAF001 AWSB ACCIDENT WELLNESS BENEFIT CLAIM FORM INSTRUCTIONS Please use black or blue ink only and print legibly when completing this form in its entirety. ... Rev 3/10 Expires 3/12 FRAUD WARNING NOTICES For use with Claim Forms PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE ALASKA: ...
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