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REQUEST FOR ADDITIONS/APPLICATION FOR REINSTATEMENT ACCIDENTAL MEANS ONLY INSURANCE FOR A35000 SERIES American Family Life Assurance Company of Columbus Aflac Worldwide Headquarters Columbus GA 31999 For information call toll-free 1-800-99-AFLAC 1-800-992-3522 Name of Policyholder SSN Optional Policy Number Date of Birth Current Address of Policyholder City State ZIP Telephone No. Former Address of Policyholder Name of Employer Associate/Agent Signature and Writing Number Licensed...
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