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If the accident resulted from the use of a motor vehicle(s), a copy of the police or accident report is required. Z'qla+"Ni'F7cdihoHcj(u=..e%DbtGJWZF/nB*]I!`;q;hE9aN=iqM2-6r0A.0!kYlX,(D 8;U4*8AZ=@b:l^dJ*L_0.&7i0E^jm_'-W 55184 <>stream cC5a$qEUFt(E8e->F3f^Yr:J8cr+o+V8SWC.sUDP!9a:YTD`h-6Dlku'HCEL>"u[SakEau jPHFW8nlme]HU. )lM~> endobj Gb"/l>AkOk&]_Z/^,64CCgQh(QQim(`'@6(M1VCS?Ymokm)Y?"923o3hrP9g4Yu*CcB6B*!?;6YT@s1*_r:*jjIVWN?8SPT[V>.M20U,P9l'4iI6TPY-]L!#f3%M(`,YCfUG&+3=,h@oh'%%R8_;#D97$7DPAU-\'4cMbSmaD1quDo:PhC8FAQ_/2XZE4Kg#d',UPm7ke>cGNcuWsA1Re6L<8TPh=9[*Pk3kf]HG?:]j+f^e0da8lF5rcV:E%B=r3G;%R(Xf":ZPhD;HI=o2=W1:skhAOSf)4$6[Y*hA_qQ>#XK+S'ZUkOIKD*iLBqMO1XS"!cLPYd()UE9Lm2lr6Mn03Uc=D9cmg9ZFLR'j#lTAS?p0fFMITB#ShK:pcr`bu\*p_7fncO=H:Cg))Dh,V>4bK>oW$PT7aee,0TKjD0nWW>XIsXWdMeY)H^W"J?KP[.,0T5VP[&"V-R*m\g;oH$Xg-3^E`2UO>b:S!S#%Ni>r1U>7W]WVl%FBJ6EJLK\e5S/p'%Rhg`ig(XQcq,`dM"Z"a`kcZ-'(jE_+^$?7s6^cGj474dI*df2J-e5q=Y_1b16H?P]03X?3K>qnsh^!G`9eSL__s6U1M*9Teo45)s'E#TeBH)kV0Og)S^AO+J(2F[da5RA>ICW7:^P&t'LLAnd0HKr&IpsIn8SeU(:Jc=*pS?k-99YCErn>UJX-`Hn%(aqln*&$XIcANS4VpU[QLj]G!;#@EAKq^@j,u;`/,(/Na!g5q"Yh65\"D,!aB.Em\'n/8"7*<31JeCqa`mMJ:h^-@Y+&*%Hi'pHjq[(V+Huac?`=P/n;ZtVYhK&jU4+P;,;Li0RY7*b9.,B=i>Eeq&&>XEt+0g%csST^gUX`O)f4L?@mpN=*2KGID@n!ahWqW<0.bbeua0:q(o7]2r0OVPUZgknmZaeqoclXGYUp'!2bS=sHp[\G[PG!Smtge^H`:p@^73,cnK$pco"N52fZ7k,?t_TBa6[Yo38a*bPjO'L>&jO>C.hg#O#*qQR%MfmPB/pb=.ds3hbk[@d1B`!QLOun.$sgs3XfN'9kHM]j^-B:=S5hBb`)3Y[+?"%4"O*G7.WL:[M7VEor0!>;%F[GQFZUW-817ADTaR](EM)4B>C4br^N)Q@KkkpNbQ$O`Ai!OQG#u9I'pD\EjH. <> c)$el$_7T'R>`H4d?VZZ.6:FXa^5[8hKt_jJ5`+n^Hma14HF`L'+tk,U=9slnfp8]Z?2MS[;()=`R 1EWs%t3I_6o#k'G^.VY7l!4E5fU,kWcMcPcnu9Vps@:V.*1hGHiRR-8n&.Gf>KTA_?ia$;;29=Lp*@; =[GYSI.i$`\)6Yek?R3(hf\K7.q'`4X>.c*a*j"/k@0B+Aq? 24 0 obj )S.%6`+GjIZj](Q#<=c@2$Z7dM/>T[*ou6=\86%`.6Tf9_%C^ECG2N>a#UsXf8l(9b*mV6r!V.s)b^~> Mail: Post Office Box 84075, Columbus, GA 31993, For critical illness claims, we need information from you and your attending physician. >> 0000054442 00000 n XjUu*Xp,0:=B'1\[JFP0hMrY:2"oGp)9[K*JFW%Q,%O]LqIHbC]M^O"otS`QEp1e73#AH7.C_?r+Be5\ 2 0 obj mQYc=\E9,ERP]c]=8bqqqY%CP/fB'k8=no-Ws101`o*'eZs]oap*qMF endobj endobj $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR 21 0 obj <> endstream (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!AicdVn^"gp(^-oKqo#i"gBOsIn1fK.\PJgLt&^imq7BSJ..gu`g3TNp]lZQ:Q+PSQZ=7bSOhN`;B#7;s#7r)aO+XB?-BFdCkA(+.VnQp*5O$?iSK/`O.QJ'S)/aPDmhO:I1AIuZ^Ves%d@6'UQ5gRhf3BF`kXpaej\IRil\Y_Tp',^\5b3DiW.2X/9G,ZBZNQ1%0jnNTP=-/t4]pG5O*!$Hj%$(Vi!33gU7QS]rt"S4I%1~> Business owner? 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No Yes Isdisabilityduetoaninjury? endobj endobj 9srK>"cZ(SQ7f&_@XkjoOD9.JoV5["B)lrLk1"RN#NAQ@Io/k:h_VaFk%A]Xes%eU0Lr%f7V@nha@^3[ <> s(a2"ShqZon2tUR"gff@QgRi&=8T@kgq-(JZ&gl35W-8HGs$[[cMe Dental and Vision plans are administered by Aflac Benefit Solutions, Inc. %PDF Font (F2) fU$\OG4-O2)(5'UZNJ?f73M.5b:i7_h](4!r@! [lXipns%dYmtWgT45TNAg1!L7&LsF1AVS8,9_:a+p=0JYXs63uqK)DZMF:+=COnscG]5l!0l_(jD#HTn3T/Nq3TXul_X>mcZ"L&H2kUp].^k.4,_Aof>Ug=,=b3fQf+d*!6h*m;*04i'C0/[p+\Sgs.&*IjrlVLg~> endobj aflac continuing disability claim form Summary of Benefits for Benefits Eligible Employees Mar 31, 2022 Employees are covered by long-term disability insurance, beginning on the first day of employment. XL9IY_,^5e)u%m(QSW8`,Ms+JJ"IKSqK)]ClhR1"S67]3AnXNZbU5t!S#5jg;<=EaA8%\YmR9]u3\kc^ m);lB2NZG/rMHahB@? "k&*mXEOTDY; The Disability Claim Form (Aflac Insurance) form is 8 pages long and contains: Use our library of forms to quickly fill and sign your Aflac Insurance forms online. "-e/G/_P"pf.N+3cau8Z.,JJ6Rk;MRVJDs 0000054624 00000 n (D;A)'1,bTSu(P!sL=W[AP?iW[gGM >> >> e(d`r+1(IK_Z9J8FZEKhh]p"mOP2o\*_i:B,oR:q;pr&)1JfnGrF_2WN1&RdVP7b@X=`\9QI&,k/0N4e mhQCujn[DM`k5Vu9TL8/lY,n@)69`YnLctGSmP1C9g-Y\7nk0=`m#b/(aquK(k!OU2OhA)L%au^_^KfM <>stream No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . Yku1YRdk^9;TD\;*kl4jYjTa8Xl"SC:fUS)e;!AcrDK#l16`LFaGhEJ;`,G>'H*8^Jr\^>/E?FZ]1S?b :^_n)prV#UtcF7_C)h7^7 You can now make your claim online by accessing your online account. 0000000446 00000 n ?/8-TEfAU,j[:b-G[DjC57H"+$-Ag(@hZ 1g!5D-LsIWRBY-X(8X2r&@O_`0*:d@O.-Wcm!Ja'h?grDR1Nq&[A-=2b! 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"tZ ;dps@dXdX$3sN65dLrqK;34,XZ>#G6k1;= 0000040092 00000 n 0000030858 00000 n 24 0 obj 0h_D=!TqJR_)(mgd\>#ol+75J9jtBIKFJ@V(i4JVZqc++3o&'Oo?S]N51A'u=i0pZ1o;C9[qgcc?S#Dh File a Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claim, File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company Claim, File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company, Do Not Sell or Share My Personal Information. 0000055102 00000 n <> A0Y5rjtc-l=mpq_h=;$=@msV1)_!YAgb[=l4d[#_f!$4lHeElf,p`grp.1a3BKs:! ;Y'TZ`#NiWQ /Title (New Claim Form PDFs for WEB - S00224) Download the data file or print out your PDF version. nhH(@HB3(k..$A&2I&hNumCF[&]PjI*`R_D2M6]X>#-E#f;915&(PF6%>9Knd"E.:PO 20 0 obj 0000000009 00000 n R5BsS,N[X$9*1Su`V5!FLu53L/`5$Sl[7rqO,!^]g&GFP&S?ljI>6jN,bnDr8aF$lN\@CTOcGe"W!E$o