Fillable Aflac Accelerated Death Claim Form V8 16

Fill Online, Printable, Fillable, Blank Aflac Accelerated Death Claim Form V8 16 Form

Use Fill to complete blank online AFLAC INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Aflac Accelerated Death Claim Form V8 16

On average this form takes 26 minutes to complete

The Aflac Accelerated Death Claim Form V8 16 form is 5 pages long and contains:

  • 10 signatures
  • 14 check-boxes
  • 59 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Aflac Insurance forms online.

BROWSE AFLAC INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Aflac V8.16
Accelerated Death Benefit Claim
Section A – Insured Information Policy / Certificate #: _________________
Name: ______________________________________ DOB: ____/____/____ SSN: _______________________
Address: _____________________________________________________________________________________________
Street City State Zip Code
Phone #________________________ Home Cell Work E-Mail Address: ___________________________________________
Occupation __________________________________________________________________________________________________
Current Illness __________________________________________________________________ Date of Diagnosis: ____/____/____
*** Complete & Sign Disclosure Authorization Portion of Claim Form ***
Section B – Attending Physician’s Statement
(To be completed by the Attending Physician)
Name of Patient: ____________________________________ Patient I.D. Number: ________________________
Please state diagnosis: _______________________________________________________________________________________
Describe nature & cause of injury or condition: _____________________________________________________________________
Date of symptoms first occurred: ____/____/____ ICD-10 Code: _______________________________________
Has patient had same or similar condition? Yes No If yes, when? ____/____/____
If no, what are the contributing factors?____________________________________________________________________________
List all dates of treatment: ______________________________________________________________________________________
List all prescribed treatment: ____________________________________________________________________________________
List present medications: _______________________________________________________________________________________
Is patient hospitalized?
Yes No If yes, give dates: ____________________________________________________________
Hospital Name(s): ____________________________________________________________________________________________
Hospital Address: _____________________________________________________________________________________________
Street City State Zip Code
Phone #________________________
Name of Referring Physician (if applicable):_________________________________________________________________________
Address: ____________________________________________________________________________________________________
Street City State Zip Code
Prognosis: __________________________________________________________________________________________________
After a thorough, extensive medical review, I have concluded that _____________________________________ is terminally ill
and is anticipated to only survive the next ______ months.
Physician’s name (please print)_____________________________________________ Specialty_____________________________
Phone: _____-_____-_______ Fax: _____-______-_____
Address: _____________________________________________________________________________________________
Street City State Zip Code
Signature___________________________________________ Date ____/____/____
click to sign
signature
click to edit
For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Aflac V8.16
Accelerated Death Benefit Claim
State Required Fraud Warnings
Fraud Statement for Alaska and New Hampshire Residents: A person who knowingly and with intent to injure, defraud or deceive an insurance
company, files a claim containing false, incomplete or misleading information may be prosecuted under state law.
Fraud Statement for AZ Residents: 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.
Fraud Statement for CA Residents: For your protection, California law requires the following to appear: 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.
Fraud Statement for CO Residents: 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 or 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.
Fraud Statement for FL Residents: 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.
Fraud Statement for Kansas, and Oregon Residents: Any person who knowingly, and with the intent to injure, defraud, or deceive an insurance
company, files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance fraud, which may be a crime.
Fraud Statement for KY Residents: A 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.
Fraud Statement for Arkansas, Louisiana, New Mexico, Texas, and West Virginia Residents: 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.
Fraud Statement for Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit
or 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.
Fraud Statement for MN Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
FRAUD STATEMENT FOR PENNSYLVANIA RESIDENTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON FILES ANY 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.
Fraud Statement for 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 Statement for Ohio Residents: 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.
FRAUD STATEMENT FOR DISTRICT OF COLUMBIA, MAINE, TENNESSEE, VIRGINIA AND WASHINGTON RESIDENTS: 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.
Fraud Warning for Delaware, Idaho, Indiana, and Oklahoma, As Well as for the Residents of All States Not
Specifically Listed WARNING: Any person who knowingly, and with the intent to injure, defraud, or deceive an insurance
company, files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance
fraud, which is a felony.
For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Aflac V8.16
Accelerated Death Benefit Claim
DISCLOSURE AUTHORIZATION The following disclosure is made pursuant to the Fair Credit Reporting Act:
Please be notified that, as a result of our regular claims investigation procedures, an investigative consumer report may be
prepared, whereby information received from third parties is obtained from an independent inspection company. You have the
right to make a written request within a reasonable period of time to receive detailed information about the nature and scope of
this investigation.
Authorization:
I authorize any physician, medical practitioner, hospital, clinic or other medical or medically related facility, Veterans
Administration or government agency to furnish all information and copies of records regarding health care or treatment
provided me, including, but not limited to, admitting records, hospital records, test records, finding and diagnostics. Such
information and records shall be provided to a representative of the Claim Department of Trustmark. The information obtained
by this authorization is for use solely to determine my eligibility for insurance benefits. This authorization includes information
about drugs, alcoholism or mental illness.
I authorize my present or past employer(s) to supply information covering the status of my employment, job duties, days absent
from work and training provided. This information may be provided to a representative of Trustmark and is to be used solely to
determine my eligibility for insurance benefits. Any information obtained will not be released by Trustmark to any person or
organization.
I further authorize Trustmark to release all copies of medical records collected during its investigation to a second physician (and
third, if required). I further authorize this statement to be copied and the copy utilized as if it were an original. I understand that
upon request I have a right to obtain a copy of this authorization. I understand this authorization will remain valid for one year
from this date.
I understand that failure to sign this authorization may delay the payment of my claim.
Owner’s Signature: ______________________________________ Date Signed: ___/___/___
Signatures Required
I have read the statement on this form and concur with them. I am of sound mind and have advised my beneficiaries, the executor
of my estate, and my attorney of my action and have instructed that I alone am responsible for seeking this benefit. If the
Accelerated Death Benefit is advanced to me, my executor, assignees, beneficiaries and I agree to hold Trustmark harmless and
free from all liability for having advanced this death benefit.
Insured/Claimant Signature: ______________________________________ Date Signed: ___/___/___
Spouse Signature: ______________________________________________ Date Signed: ___/___/___
(If a Community Property state. I hereby forever waive all community property right and claims to any funds paid pursuant to
the Accelerated Death Benefit and agree that said check should be made payable to the owner).
Owner Signature: _________________________________________________ Date Signed: ___/___/___
(if other than insured)
Joint Owner Signature: _____________________________________________ Date Signed: ___/___/___
(if applicable)
Irrevocable Beneficiary Signature: ____________________________________ Date Signed: ___/___/___
(if applicable, I hereby forever waive all rights and claims to any funds paid pursuant to the Accelerated Death Benefit and agree
that said check should be made payable to the owner.))
Notarized Signature: _______________________________________________ Date Signed: ___/___/___
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Aflac V8.16
Accelerated Death Benefit Claim
Insured Statement of Claim – Communication
1. CONSENT FOR USE OF ELECTRONIC COMMUNICATIONS (EMAIL, SMS/MMS TEXT MESSAGING)
To ensure the best and fastest communication, we would like to communicate with you using either email or text
messaging. Please complete this section if we can communicate with you electronically, concerning your claim, benefits,
policy, premium or condition.
May we communicate with you electronically?
No
Yes, by Text Messages - Please provide cell phone #: (_____) - ______ - ______
Yes, by Email Please provide email address: ________________________________________@ _______________
If you chose to communicate with us electronically, you should be aware that electronic communication is not secure
unless it is encrypted. We strongly encourage you to use encrypted communication when sending sensitive and/or
confidential information. By sending sensitive or confidential electronic messages that are not encrypted, you accept the
risks of such lack of security and possible lack of confidentiality. If you elect to communicate from your workplace
computer, you should also be aware that your employer and its agents, have access to electronic communication
between you and us.
I understand that by selecting text messaging, regular text messaging rates may apply for any texts I receive from
Trustmark and I assume responsibility for any costs associated with these text messages. This consent shall remain in
effect unless revoked in writing.
To ensure a smooth email experience, please be sure that your computer has the most up to date version of Adobe
Reader. You should add our email address to your address book contact list and add us to your email server or spam
filter approved listing. If you don’t see email from us in your email inbox, be sure to check your spam, clutter, junk or
bulk email folder. You can choose to stop electronic communication at any time by revoking this authorization. If you no
longer wish to communicate via electronic means we will correspond with you via US mail. If you require copies of any
communication sent to you by email/text in paper form, please contact us. There is no cost to you to obtain copies of
electronic communication in paper format.
Authorization
I may revoke or update this authorization in writing at any time or by email to
Claims@ULAflac.com.
Trustmark Insurance may rely on the information I provide for the adjudication of my claim as a result of this
authorization until receipt of my revocation notice. This authorization is valid for two (2) years. I may request a copy of
this authorization and a copy is as valid as the original.
Policy Owner Signature Date
Printed Name Social Security Number
click to sign
signature
click to edit
For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Aflac V8.16
Accelerated Death Benefit Claim
Insured Statement of Claim – Communication (Continued)
2. Third Party Communication Authorization
Please complete this authorization if you would like us to discuss, to release, or to provide information to a family
member, friend, or other third party such as your agent or employer.
My Spouse or Partner: (Name)_______________________________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
My Family Member: (Name and Relationship)_____________________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
Other Third Party: My Agent: Yes ☐ My Employer: Yes ☐
Or Name a Specific Third Party (Name and Relationship) ___________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
I agree that if I authorize release of all claim information this may include health information which may be related to
disorders of the immune system including but not limited to HIV and AIDS, use of alcohol or drugs, mental and physical
condition, history, or treatment.
I understand that any information shared may be subject to re-disclosure and might not be protected by certain federal
regulations governing the privacy of health information relative to my condition.
Authorization
I may revoke or update this authorization in writing at any time or by email to
Claims@ULAflac.com.
Trustmark Insurance may rely on the information I provide for the adjudication of my claim as a result of this
authorization until receipt of my revocation notice. This authorization is valid for two (2) years. I may request a copy of
this authorization and a copy is as valid as the original.
Policy Owner (Or Policy Owner’s Personal Representative’s Signature Date
- -
Printed Name Social Security Number
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Aflac Accelerated Death Claim Form V8 16

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document