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Please complete this section only for W-2 Employees and/or Contract 1099. (Please contact payroll and/or check the policyholder’s Salary Redirection Agreement/Premium Deduction Authorization card for the answer to these questions.)
SHORT TERM DISABILITY CLAIM FORM. PART B: EMPLOYER’S STATEMENT: (To be completed by your Benefits/Human Resources Department unless self-employed) IF SELF-EMPLOYED, PLEASE SUBMIT 1099 FORM FOR VERIFICATION. IF EMPLOYEE IS RECEIVING ANY OTHER INCOME, PLEASE SPECIFY TYPE AND AMOUNT OF INCOME.
PolicyholderInformation:This*denotesarequiredfield. *PolicyNumber: / / - --PatientInformation: *LastName Suffix *FirstName MI *DateofBirth(mm/dd/yy ...
File your claim via fax or mail. Consider filing online for faster claims payment! Download form
The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee’s Form W-2. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company.
Forms: Disability Claim Form. Continuing Disability Claim Form. If this is a Disability Product with your policy number beginning with AFL, please use the form below. Short Term Disability/Long Term Disability Claim Form
My Claims. Follow your claim from start to finish and receive alerts if we need additional information through our integrated Claim Status Tracker. My Coverage. Here you’ll find a copy of your policy and benefit details to see what’s covered and benefit amounts. My Account.
INITIAL DISABILITY CLAIM FORM. Thank you for trusting Aflac with your Initial Disability needs. â If you are interested in uploading documentation on an existing claim, register using aflac.com/smartclaim. To prevent delays, please provide documentation from your healthcare provider to support this claim.
Submit the completed statements to the address below, fax to 1-(866) 376-9480, or scan the completed statements and email to AFLACclaims@disabilityrms.com. All portions of these forms must be completed in order to expedite your claim.
Note: This form is for initial filing of a disability claim. If your disability is being extended, you will need to complete the listed Supplemental Claim form.