Fill - Free fillable Accidentclaimform Group Accident Claim Form (Aflac Insurance) PDF form

Post Office Box 84075 * Columbus, GA. 31993

Phone (800) 433-3036 * Fax (866) 849-2970

groupclaimfiling@aflac.com

ACCIDENT CLAIM FORM INSTRUCTIONS

To avoid delays in processing of your claim form, complete each section attaching documentation below

when it applies.

Supporting Documentation Needed

 Itemized bill if there was a hospital stay (UB04 from the hospital or medical facility)

 Chart Note to include admission and discharge paperwork if there was a hospital stay

 Itemized bill from physician’s office (HCFA 1500 from treating physician’s office)

 Surgical Report if accident involved surgery

 Ambulance bill if emergency transport was required

 Appliance receipt if crutches, wheelchair or other medical equipment was required

 Follow Up Visit-receipts for follow up visits or physical therapy with dates and charges if applicable

 Xray/Diagnostic Tests-receipts with dates and charges if applicable

 Accident Report-if applicable (ex: police report)

 Benefit Assignment-Benefits are payable to the policy holder unless written authorization is

received from you or your healthcare provider to assign benefits to the provider. If you choose to

assign benefits, attach a signed and written request.

 Email form to groupclaimfiling@aflac.com or fax to 1.866.849.2970.

Post Office Box 84075 *Columbus.GA.31993

Phone (800) 433-3036

Fax

(866) 849-2970

groupclaimfiling@aflac.com

ACCIDENT CLAIM FORM

AUTHORIZATION

Several states require that the following statement appear on claim forms. Any person who knowingly and with

intent to defraud

any insurance company,

files a statement

of claim

containing any materially false,

incomplete or misleading information, is guilty of crime.

hereby certify

that

the answers I have made

the foregoing questions are

both

complete and

true to the

best of my knowledge and belief. I have read the

fraud

notice included in this form.

Policyholder's Signature: Date:

Patient's

Signature: Date:

POLICYHOLDER/PATIENT INFORMATION

*By providing your email address above, you consent to the use of electronic transactions in connection with your CAIC policies,

contracts, and/or account to the extent available and permitted by law (which may include, but not limited to: invoices, claim

correspondence, contracts, surveys, and other materials that CAIC is, or may be legally required to deliver to you). Additionally, by providing

your email address you consent to being contacted or processing transactions by automated machines regarding your CAIC policies.

• Date of injury

• Describe how the injury occurred:

• Was

this injury caused by an incident

that occurred while performing the duties of his/her employment?

• Has a Worker's Compensation claim been filed?

if yes, status of the claim: Approved Pending Denied

• Was the patient injured in a motor vehicle accident?

(If yes, please submit the Police Report.)

Yes No

• Was death a result of this injury?

Yes No

(If yes, please submit the certified death certificate and the Life-Beneficiary's Statement.)

Yes No

EMPLOYER’S NAME POLICYHOLDER’S EMAIL ADDRESS

POLICYHOLDER’S NAME POLICY NO. SOCIAL SECURITY NO. DATE OF BIRTH GENDER

POLICYHOLDER’S ADDRESS STREET CITY STATE ZIP CODE

PATIENT’S NAME (PERSON WHO IS SICK OR INJURED) DATE OF BIRTH GENDER

POLICYHOLDER’S TELEPHONE NO.

CHECK BOX IF THIS IS A PERMANENT ADDRESS CHANGE

RELATIONSHIP TO POLICYHOLDER

Self

Spouse

Domestic Partner

Dependent

Other

Discharge Date:

Admission date:

Hospital name:

City:

State:

• Was the patient transported by an ambulance as a result of this injury? Yes No (If yes, please submit the

ambulance bill.)

• If any of the following were the result of your injury, please provide medical records or physician’s office notes:

• Coma

• Paralysis

• Degree of Burn

• Injury to the Eye

• Laceration (including length and method of repair)

• Dislocation (X-ray reports of major diagnostic exam

reports are needed)

• Concussion (Major diagnostic exam reports are needed)

• Fractures (X-ray repots on major diagnostic exam

reports are needed)

• Was an aid in locomotion (mobility) prescribed as a result of this injury? (ie: Crutches, Wheelchairs, Leg

Braces, Walking Boots, Back Braces, Walkers, Cervical Collars) Yes No

(If yes, please submit documentation from the prescribing provider.)

• Your policy covers the following surgeries:**

• Open Reduction, Internal Fixation (Fractures of

Dislocations)

• Knee Cartilage Repair

• Open Abdominal/Thoracic Surgery

• Ruptured Disc Repair

• Tendon or Ligament Repair

• Eye Surgery

o Were any of these surgical procedures performed as a result of this injury? Yes No

(If yes, please submit a copy of the operative report.)

Provide all dates of treatment related to injury on the lines below. (Please submit supporting medical documentation

for each visit indicated below.)

Initial date of treatment:

Follow up visits:

Physical therapy:

**See policy for time limit provisions.

Was the patient confined to the hospital as a result of this injury? Yes No

(If yes, please submit the certified death certificate and theLife-Beneficiary’s Statement.)

•

• Was a major diagnostic exam (ie: CT Scan, MRI, MRA, EEG) performed as a result of this condition?

Yes

No (If yes, please submit a copy of the exam report of billing.)

Primary Certificate Holder Name:

SSN(optional):

Date of Birth:

Certificate Number(s):

Address:

City:

State:

Zip:

Name of Individual Subject to Disclosure (If not the primary Certificate Holder):

Date of Birth:

Relationship to Primary Certificate Holder:

Self

Spouse Domestic Partner

Dependent

Authorization:

For the purpose of evaluating my eligibility for insurance and for benefits under an existing certificate, including checking

for and resolving any issues that may

arise regarding incomplete or incorrect information on my application for coverage

and/or claim form, I hereby authorize the disclosure of the following

information(defined below) about me and, if

applicable, my dependents, from the sources listed below to Continental American Insurance Company (CAIC), or

any

person or entity acting on its part, to include American Family Life Assurance Company of Columbus and American

Family Life Assurance Company of New

York (collectively, “Aflac).

II.

Disclosure of Health Information:

Health information may be disclosed by any health care provider, health plan (including CAIC or Aflac, with respect to other

CAIC or Aflac coverages) or health care

clearinghouse that has any records or knowledge about me. Health care provider

includes, but is not limited to, any licensed physician, medical or nurse practitioner,

nurse, pharmacist, osteopath,

psychologist, physical or occupational therapist, chiropractor, dentist, audiologist or speech pathologist, podiatrist, hospital,

medical

clinic or laboratory, pharmacy, rehabilitation facility, nursing home or extended care facility, prescription drug

database or pharmacy benefit manager, or ambulance

or other medical transport service. Health information may also be

disclosed by any insurance company or the Medical Information Bureau (MIB). Health

information includes my entire

medical record, but does not include psychotherapy notes. Some information obtained may not be protected by certain

federal

regulations governing the privacy of health information, but the information is protected by state privacy laws and

other applicable laws. CAIC will not disclose the

information unless permitted or required by those laws.

III.

Rights and Expiration:

I understand that I may revoke this authorization at any time, except to the extent that CAIC or Aflac has taken action in

reliance on this authorization. If I revoke

this authorization, CAIC may not be able to evaluate my application for coverage

and/or claim. To revoke this authorization, I must provide a written and signed

revocation to CAIC at the address or fax

number above. Unless otherwise revoked, this authorization shall remain in effect for two (2) years from the date signed

or upon my death, whichever occurs first. I agree that a copy of this authorization is as valid as the original and that I or an

authorized representative may request

a copy of this authorization.

IV.

Notice:

I understand that CAIC is not conditioning payment, enrollment, or eligibility for benefits on whether I sign this

authorization. I understand that if the

information disclosed is protected health information relating to a health plan and the

person or entity receiving the information is a not a health care provider

or health plan covered by federal privacy

regulations, the information disclosed may be re-disclosed by such person or entity and will likely no longer be

protected

by the federal privacy regulations.

•

If records are on an adult dependent, (e.g. spouse, child over 18), the dependent must sign this form

•

If records are on a minor child the natural parent or legal guardian must sign on their behalf.

Signature of Individual Subject to Disclosure Date Signed

Legal Representative’s Printed Name

Legal

Representative’s Signature Legal Relationship Date

Legal Relationship would include, but is not limited to, Legal Guardian, Estate Administrator, Power of Attorney, etc.

Send to:

Continental American Insurance Company

Post Office Box 84075

Columbus, GA 31993

Phone: (800) 433-3036

Fax: (866) 849-2970

Email: groupclaimfiling@aflac.com

AGC06106_2016

AUTHORIZATION TO OBTAIN INFORMATION

Other _____________________

Send to: Continental American Insurance Company Phone: (800) 433-3036 Fax (866) 849-2970

Post Office Box 84075

Email: groupclaimfiling@aflac.com

Columbus, Georgia 31993

Authorization Agreement for Direct Deposit

I would like to: Start Stop Change direct deposit of my claim payment(s).

Account Type:

Checking Savings

**** Please provide a blank voided check or

direct deposit form from your financial

institution. Incomplete or inaccurate

information will not be processed.

9-Digit Routing Number: Account Number:

Name of Financial Institution:

Address: City:

State: Zip: Phone:

I authorize Continental American Insurance Company (CAIC) to initiate credit entries, and, if errors occur, I authorize

the correction of entries to my account as indicated. This authorization remains effective and in full force until

CAIC receives written notification from me of its termination in such time and in such manner to afford CAIC a

reasonable opportunity to act on it. Please notify CAIC immediately if your financial institution information has

changed by sending notification to the address indicated above. Should you have any questions, please contact us at

1-800-433-3036.

Policy/Certificate Holder’s Name (Print):

Address: City/State/Zip:

Phone #: E-mail Address:

Employer Name or Group #: Certificate #:

***By providing your e-mail address above, you consent to the use of electronic transactions in connection with your CAIC policies, contracts, and/or

accounts to the extent available and permitted by law (which may include, but not limited to: invoices, claim correspondence, contracts, surveys, and

other materials that CAIC is, or may be, legally required to deliver to you)

Note: Forms received without signature will not be processed. Electronic signatures not accepted.

Policy/Certificate Holder Signature (Required) Date Signed:

Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. Aflac is

not licensed to

solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. For groups sitused in California, coverage is underwritten by Continental American Life Insurance

Company. For groups sitused in New York,

coverage is underwritten by American Family Life Assurance Company of New York.

Continental American Insurance Company • 1600 Williams St • Columbia, South Carolina 29201 • 1-800-433-3036 toll-free • 1-866-849-2970 fax

EFT Form 2016

Electronic Funds Transaction Authorization

FRAUD WARNING NOTICES

For use with Claim Forms

PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE

ALASKA:

A person who knowingly and with intent to

injury,

defraud or deceive an insurance company files a

claim

containing false, incomplete, or misleading

information may be

prosecuted under state law.

IDAHO:

Any person who knowingly, and with intent to

defraud

or deceive any insurance company, files a

statement of claim

containing any false, incomplete, or

misleading information is

guilty of a felony.

ARIZONA:

For your protection Arizona law requires

the

following statement to appear on this form. Any

person who

knowingly presents a false or fraudulent

claim for payment of a

loss is subject to criminal and

civil penalties.

INDIANA:

A person who knowingly and with intent to

defraud

an insurer files a statement of claim containing

Any false,

incomplete, or misleading information

commits a felony.

ARKANSAS:

Any person who knowingly presents a

false or

fraudulent claim for payment of a loss or benefit

or knowingly

presents false information in an application for insurance is

guilty of a crime and may be

subject to fines and confinement

in prison.

KENTUCKY:

Any person who knowingly and with intent to

defraud any insurance company or other person files a

statement of claim containing any materially false information

or conceals, for the purpose of misleading, information

concerning any fact material thereto commits a fraudulent

insurance act, which is a crime.

CALIFORNIA:

For your protection California law

requires the

following to appear on this form:

Any person who knowingly presents a false or

fraudulent claim

for the payment of a loss is guilty of a

crime and may be subject

to fines and confinement in

state prison.

LOUISIANA:

Any person who knowingly presents a

false or

fraudulent claim for payment of a loss or benefit

or knowingly

presents false information in an application

for insurance is

guilty of a crime and may be subject to

fines and confinement

in prison.

COLORADO:

It is unlawful to knowingly provide false,

incomplete, or misleading facts or information to an

insurance

company for the purpose of defrauding or

attempting to

defraud the company. Penalties may

include imprisonment,

fines, denial of insurance and civil damages. Any insurance

company or agent of an insurance company who knowingly

provides false,

incomplete, or misleading facts or information

to a

policyholder or claimant for the purpose of defrauding

attempting to defraud the policyholder or claimant

with regard

to a settlement or award payable from

insurance proceeds

shall be reported to the Colorado

division of insurance within

the department of regulatory agencies.

MAINE:

It is a crime to knowingly provide false,

incomplete or

misleading information to an insurance

company for the

purpose of defrauding the company.

Penalties may include

imprisonment, fines or a denial of

insurance benefits.

MARYLAND:

Any person who knowingly and willfully

presents

a false or fraudulent claim for payment of a loss

or benefit or

who knowingly and willfully presents false

information in an

application for insurance is guilty of a

crime and may be

subject to fines and confinement in

prison.

DELAWARE:

Any person who knowingly, and with intent to

injure, defraud or deceive any insurer, files a statement of

claim containing any false, incomplete or misleading

information is guilty of a felony.

MINNESOTA:

A person who files a claim with intent to defraud

or helps commit a fraud against an insurer is guilt of a crime.

DISTRICT OF COLUMBIA: WARNING:

It is a crime to provide

false or misleading information to an insurer for

the purpose of

defrauding the insurer or any other

person. Penalties include

imprisonment and/or fines. In

addition, an insurer may deny

insurance benefits if false

information materially related to a

claim was provided

by the applicant.

NEW HAMPSHIRE:

Any person who, with a purpose to injure,

defraud, or deceive any insurance company, files a

statement

of claim containing any false, incomplete, or misleading

information is subject to prosecution and punishment for

insurance fraud, as provided in RSA 638:20.

FLORIDA:

Any person who knowingly and with intent

to injure,

defraud, or deceive any insurer files a

statement of claim or an

application containing any

false, incomplete, or misleading

information is guilty of

a felony of the third degree.

NEW JERSEY:

Any person who knowingly files a statement of

claim containing any false or misleading

information is subject

to criminal and civil penalties.

FRAUD WARNING NOTICES (CONT.)

For use with Claim Forms

PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE

NEW MEXICO:

Any person who knowingly presents a

false or

fraudulent claim for payment of a loss or benefit or

knowingly

presents false information in an application for

insurance is

guilty of a crime and may be subject to civil

fines and criminal

penalties.

TENNESSEE:

It is a crime to knowingly provide false,

incomplete or misleading information to an insurance

company

for the purpose of defrauding the company.

Penalties include

imprisonment, fines and denial of

insurance benefits.

NEW YORK:

Any person who knowingly and with

intent to

defraud any insurance company or other person

files an

application for insurance or statement of claim

containing any

materially false information, or conceals

for the purpose of

misleading, information concerning

any fact material

thereto, commits a fraudulent insurance

act, which is a crime,

and shall also be subject to a civil

penalty not to exceed five

thousand dollars and the stated

value of the claim for each

such violation.

TEXAS:

Any person who knowingly presents a false or

fraudulent claim for the payment of a loss is guilty of a crime

and may be subject to fines and confinement in

state prison.

OHIO:

Any person who, with intent to defraud or knowing

that

he is facilitating a fraud against an insurer, submits an

application or files a claim containing a false or deceptive

statement is guilty of insurance fraud.

VIRGINIA

: It is a crime to knowingly provide false,

incomplete

or misleading information to an insurance

company for the

purpose of defrauding the company.

Penalties include

imprisonment, fines and denial of

insurance benefits.

OKLAHOMA: WARNING: Any person who knowingly, and with

intent to injure, defraud or deceive any insurer, makes any claim

for the proceeds of an insurance policy containing any false,

incomplete or misleading information

is guilty of a felony.

WASHINGTON:

It is a crime to knowingly provide false,

incomplete, or misleading information to an insurance

company for the purpose of defrauding the company.

Penalties include imprisonment, fines, and denial of insurance

benefits.

OREGON:

Any person who, with intent to defraud or

knowing

that he is facilitating a fraud against an insurer, submits an

application or files a claim containing a false or

deceptive

statement may be guilty of insurance fraud.

RHODE ISLAND and WEST VIRGINIA:

Any person who

knowingly presents a false or fraudulent claim for payment

a loss or benefit or knowingly presents false information

in an

application for insurance is guilty of a

crime and may

subject to fines and confinement in prison.

PENNSYLVANIA

: Any person who knowingly and with intent to

defraud any insurance company or other person

files an

application for insurance or statement of claim

containing any

materially false information or conceals for

the purpose of

misleading, information concerning any fact

material thereto

commits a fraudulent insurance act, which

is a crime and

subjects such person to criminal and civil

penalties.

ALL OTHER STATES:

Any person who knowingly and with

intent to defraud any insurance company or other person

files an application for insurance or statement of claim

containing any materially false information or conceals for

the

purpose of misleading, information concerning any fact

material thereto commits a fraudulent insurance act, which

a crime and subjects such person to criminal and civil

penalties.

PUERTO RICO:

Any person who knowingly and with the

intention of defrauding presents false information in an

insurance application, or presents, helps, or causes the

presentation of a fraudulent claim for the payment of a

loss

or any other benefit, or presents more than one claim

for the

same damage or loss, shall incur a felony and,

upon

conviction, shall be sanctioned for each violation with

the

penalty of a fine of not less than five thousand dollars ($5,000)

and not more than ten thousand dollars ($10,000), or a fixed

term of imprisonment for three (3)

years, or both penalties.

Should aggravating circumstances

are present, the penalty thus

established may be increased

to a maximum of five (5) years, if

extenuating circumstances are present, it may be reduced to a

minimum of two (2) years.

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Accidentclaimform Group Accident Claim Form (Aflac Insurance)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Accidentclaimform Group Accident Claim Form (Aflac Insurance) Form

Related forms

Fillable Accidentclaimform Group Accident Claim Form (Aflac Insurance)

Fill Online, Printable, Fillable, Blank Accidentclaimform Group Accident Claim Form (Aflac Insurance) Form

Related forms

First 20 documents completely FREE!