Supplemental

Prescription Drug Plans

Medical Savings Accounts

Forms

Aflac Benefit Services/Flex One

application for insurance or statement of claim containing any materially false information or conceals for the

28: CT HIP_ACC WLB WEB FORM - Aflac

For your protection California law requires the following to appear on this form Any person who knowingly

Flexible Spending account participant resource Guide - Aflac

File Electronically - MyAflac Resources Aflac

QUARTERLY STATEMENT OF THE American Family Life Assurance Company of Columbus (Aflac) Of Omaha in the state of NE to the Insurance Department of the State of For the Period Ended March 31, 2012 2012 LIFE AND ACCIDENT AND HEALTH COMPANIES -

Company of New York

BONE MARROW DONOR SCREENING BENEFIT CLAIM FORM

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Please fax this signed and completed form to (706) 596-3477

Hospital Indemnity Policy Number

to complete processing of this claim

Cancer Screening - Aflac

PLAN YEAR / / / /

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26: TEST WELLNESS_LTR_RED_EDC2 - Aflac

18: CT HIP_ACC WLB WEB FORM. Net assets for period ending 12/2002 were $302,696.69

Impairment due to Accident

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19: TEST WELLNESS_LTR_RED_EDC2 - Aflac

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Accident wellness fillable form

Critical Illness CONTINENTAL AMERICAN INSURANCE ... - Aflac

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11: CA HIP_ACC WLB WEB FORM - Aflac

S VISIT BENEFIT CLAIM FORM

Check box if this is a

Send the insureds check to the agent for delivery

Any person who knowingly and with intent to defraud any insurance company or other person files an

If you are filing for disability, please complete the Initial Disability Claim Form (S00224)

59: PVB TEST PSI WEB FORM

Forms completed prior to the initial date of your

V I E W POI N T

Company of Columbus (Aflac)

aflac cw06197ca

HOME HEALTH CARE CLAIM FORM

The Hispanic Achievement Award

Cancer Screening Wellness Benefit Claim Form Please read all instructions

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4 - PDF_Claimforms_HC0014_Life

Long Term Care Continuing Claim Form - Aflac

As you may know, new health care reform regulations ... - Aflac

VISION CLAIM FORM FILING CLAIM FOR (check all that apply): Disease/Disorder of the Eye Impairment due to Accident Vision Policy Number Hospitalization Accident Policy Number Deceased - Date Deceased: / / Hospital Indemnity Policy Number

D e p e n d e n t D ay C a r e

aflac continuing disability form

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4 - PDF_Claimforms_HF004_Dental - Aflac

This form should be completed on or after the initial date of your disability, hospitalization, andor surgery

Cancer Policy Number Short-Term Disability Sickness Disability Rider Policy Number

Flex One /Flexible Spending Account Claim Form Please fax this signed and completed form to: 1-877-353-9256

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Read the article - Aflac

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Short-Term DisabilitySickness

Any person who knowingly files a statement of claim containing any false or misleading information is subject

formulir long term care

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Complete and sign Section A PolicyholderPatient Information

STATEMENT OF CLAIM FOR WAIVER OF PREMIUM

10: AZ HIP_ACC WLB WEB FORM - Aflac

Please note that these benefits are not payable for treatment within the first 12 months of the policy s effective date

Form A90070DE A90070DE.1 - Aflac

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