Fillable Aflacny Permanent Waiver Of Premium Claim Form V8 16

Fill Online, Printable, Fillable, Blank Aflacny Permanent Waiver Of Premium 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.

Aflacny Permanent Waiver Of Premium Claim Form V8 16

On average this form takes 16 minutes to complete

The Aflacny Permanent Waiver Of Premium Claim Form V8 16 form is 4 pages long and contains:

  • 4 signatures
  • 14 check-boxes
  • 41 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
Trustmark Life Insurance Company of New York, Albany, NY AflacNY V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Permanent Waiver of Premium Claim NY
Section A – Insured Information Policy / Certificate #: _________________
Name: ______________________________________ DOB: ____/____/____
Address: _____________________________________________________________________________________________
Street City State Zip Code
Phone #________________________ Home Cell Work E-Mail Address: ___________________________________________
Describe nature of sickness or injury: _____________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
On what date did you become totally disabled? ___/___/___
Are you continuously confined to your home? Yes No
If yes, please provide dates: From: ___/___/___ To: ___/___/___
What is the date of your last visit to your doctor? ___/___/___
Have you considered rehabilitation for other forms of suitable, gainful employment or been in contact with either your state Division of
Vocational Rehabilitation or a similar private Agency? Yes No
If yes, please explain: ________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Are you able to perform any duties or work for profit or hire? Yes No
When do you expect to resume work? ___/___/___
Insured’s name (please print)___________________________________________________________
Signature___________________________________________ Date ____/____/____
***Please complete & sign DISCLOSURE AUTHORIZATION section of form***
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
Trustmark Life Insurance Company of New York, Albany, NY AflacNY V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Permanent Waiver of Premium Claim NY
DISCLOSURE AUTHORIZATION
Insured’s name (Please print):____________________________________________________________
I AUTHORIZE any doctor, hospital, clinic, other medical facility or provider of health care, insurer or reinsurer, consumer
reporting agency, insurance support organization, insurance agent, employer, financial institution, the Social Security
Administration, the Internal Revenue Service, the Veterans Administration or any other organization or person having any
knowledge of me or my health to give to Trustmark Life Insurance Company of New York and affiliates or its employee
and agents, or any other consumer reporting agency any information as to cause, treatment, diagnoses, prognoses,
consultations, examinations, tests or prescriptions with respect to my physical or mental condition or information
concerning me, my occupation, employment history, earnings or finances or information otherwise needed to determine
policy claim benefits due me. This may include, but is not limited to, HIV Infection, any disorder of the immune system
including Acquired Immune Deficiency Syndrome (AIDS), driving records, mental illness, or use of alcohol or drugs.
I further AUTHORIZE the Social Security Adm. to release information or records about me to Trustmark Life Insurance
Company of New York or authorized representatives. This information is to be released in order to properly adjudicate my
claim or continue my eligibility for benefits. Please release detailed earnings for up to the last ten years and/or summary
record of total earnings and/or information from master benefit records regarding award, denial or continuing benefits.
This authorization may be revoked by me. Any such revocation must be in writing, must be signed and dated by me and
must be forwarded directly to the Trustmark Life Insurance Company of New York. I AGREE the information obtained with
this Authorization may be used by Trustmark Life Insurance Company of New York and affiliates to determine policy claim
benefits with respect to the Insured. A photocopy of this authorization is as valid as the original and I may request a copy.
This authorization will be in force for the term of coverage of the policy up to 12 months from the date shown below. I
understand that if I revoke or fail to sign this authorization or alter its content it may affect the handling of my claim
including denial of benefits under my policy.
I understand that there is a possibility of redisclosure of any information disclosed pursuant to this authorization and that
information, once disclosed, may no longer be protected by federal rules governing privacy and confidentiality.
I AUTHORIZE Trustmark Life Insurance Company of New York and affiliates to report to ICS, any dates of past or present
claims filed by me.
Residents of NY – 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 or each such violation.
Date___/___/___ Signature: _________________________________________________________
Date of Birth ___/___/___ Relationship, if other than insured: _______________________________________
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
Trustmark Life Insurance Company of New York, Albany, NY AflacNY V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Permanent Waiver of Premium Claim NY
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 Life Insurance Company of New York 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 Life Insurance Company of New York 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
Trustmark Life Insurance Company of New York, Albany, NY AflacNY V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Permanent Waiver of Premium Claim NY
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 Life Insurance Company of New York 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

Aflacny Permanent Waiver Of Premium 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