21 0 obj Had your Employer complete the Employer's Statement, and had it returned to you? ^f8SP@,%81kYF7&7>W`>g^5VpKEtLo)BHCQ9Z^%VoU(+&
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Your employer is responsible for providing the information in Part B, and your attending physician is responsible for providing the information in Part C. In addition, please read and then sign the Authorization for Disclosure of Health Information (HIPAA form) included in Part A, as well as the separate Authorization for Disclosure of Health Information (HIPAA form). Z'qla+"Ni'F7cdihoHcj(u=..e%DbtGJWZF/nB*]I!`;q;hE9aN=iqM2-6r0A.0!kYlX,(D
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In New York, coverage underwritten by American Family Life Assurance Company of New York. )qT)jZA=U\YiCp>=mtH$[\__]9X3fUD/SEtnbat`
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>> 5 0 obj Click the Get form key to open it and start editing. endstream 0000043507 00000 n m^PaP#$T,QfVQ'7kTb=#ja*O^[oT:q1qW?WH%a_Lp. For groups sitused in California, group coverage is underwritten by Continental American Life Insurance Company. *-ogCe2UsEgf\'ds_/jiZfh5I(c[]]fP=H[DUhhQ4'/;X2hk?KsbO!`rDQ2eS&bFI1P0&@J-^!k9`KO(igH\q^TX%?G:9)
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InitialDisabilityChecklist Isdisabilityduetoasickness? 9 0 obj <> Open the aflac initial disability claim form physician's statement and follow the instructions Easily sign the aflac disability claim form with your finger Send filled & signed initial disability claim form aflac or save Rate the aflac disability forms 4.7 Satisfied 292 votes be ready to get more Create this form in 5 minutes or less Get Form )_uYFAPMnh@@qLR(!tj0,JgDV:^2aU1j,Q1G5%+A&.^pn]C"PJA:oAllMYj0psPAVZ_E,8iGS^\I&;A'/E"CXIR`WpK_.^,?uB7C2c/q!Ft;r%bq\)j#XX/c~> +-,&SN`[I-M6qW3;r1s0&Z$T=BbN][5p[;h9H7KL(+uC\p]Q8pinC7ha3-F4WH*,lCOr\XdV:L)GI3LX
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