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DUCK Cancer Screening Wellness Benefit Claim Form Please read all instructions. Failure to follow these instructions will delay the processing of your claim. Do not include receipts, statements, or other documentation with this form. Your Aflac New York policy provides one Wellness Benefit per covered person, per calendar year, and this form is designed specifically for this benefit. To receive your Wellness Benefit, complete the form by following the instructions provided. Please print a separate MoreCancer Screening Wellness Benefit Claim Form. POLICYHOLDER NAME: POLICYHOLDER STREET ADDRESS: CITY, STATE, ZIP: BIRTHDATE: Your Aflac Less
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