Fillable Agi Supplemental Continuing Std Form 2015

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Agi Supplemental Continuing Std Form 2015

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CONTINENTAL AMERICAN INSURANCE COMPANY
Post Office Box 84075 * Columbus, GA. 31993
Phone (800) 433-3036 * Fax (866) 849-2970
SUPPLEMENTAL CLAIM FORM (CONTINUING DISABILITY)
(Please have completed for support of continued disability)
Claim Number:
PART A: POLICYHOLDER'S STATEMENT
NAME:
SOCIAL SECURITY/ ID #: DOB:
PHONE #: (INCLUDING AREA CODE)
ADDRESS: Please include apartment/unit number if applicable
PLEASE CHECK BOX IF PERMANENT ADDRESS CHANGE
EMAIL ADDRESS:
DATES YOU WERE CONSIDERED TOTALLY
DISABLED:
FROM: THROUGH:
DATES YOU W ERE CONSIDERED PARTIALLLY DISABLED:
FROM: THROUGH:
DATE YOU RETURNED OR EXPECT TO RETURN TO WORK:
FULL TIME PART TIME/ LIGHT DUT
*
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
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).
I, the undersigned, do hereby warrant the foregoing answers and statements to be complete and true
POLICYHOLDER’S SIGNATURE: DATE:
PART B:
EMPLOYER’S STATEMENT
DATES EMPLOYEE WAS CONSIDERED
TOTALLY DISABLED:
FROM: THROUGH:
DATES
EMPLOYEE WAS CONSIDERED PARTIALLLY DISABLED:
FROM: THROUGH:
If working light duty or part time, was the employee earning
more than 80% of the pre-disability salary?
Please
provide dates, hours worked, and earnings if the
employee returned working part-time/light duty:
DATE EMPLOYEE RETURNED OR EXPECT TO
RETURN TO WORK FULL DUTY:
FULL-TIME
PART-TIME
COMPANY NAME: TELEPHONE NUMBER:
NAME/TITLE OF REPRESENTATIVE
COMPLETING THIS FORM:
WORKED:
ADDRESS:
EMPLOYER REPRESENTATIVE AUTHORIZED SIGNATURE: DATE:
PART C:
ATTENDING PHYSICIAN STATEMENT (To be completed by physician assessing return to work capability)
DIAGNOSIS:
PROVIDE ALL DATES YOU HAVE TREATED THE PATIENT FOR THIS CONDITION:
NATURE OF SICKNESS OR INJURY; COMPLICATIONS PREVENTING THE PATIENT FROM RETURNING TO WORK:
IF
PREGNANCY RELATED, HAS THE PATIENT DELIVERED?
DELIVERY DATE:
METHOD OF DELIVERY:
PLEASE LIST ANY COMPLICATIONS RELATED TO THIS PREGNANCY THAT WOULD
EXTEND DISABILITY: (PREVENT PATIENT FROM PERFORMING NORMAL JOB FUNCTIONS)
VAGINAL
C-SECTION
WAS THE PATIENT TREATED BY OR REFERRED TO FOR ANY
OTHER PHYSICIANS FOR THIS CONDITION?
IF YES, PLEASE PROVIDE PHYSICIAN NAMES, ADDRESSES, AND TELEPHONE NUMBERS:
DATES PATIENT WAS CONSIDERED TOTALLY DISABLED:
FROM:
THROUGH:
DATES
PATIENT WAS CONSIDERED PARTIALLLY DISABLED:
FROM: THROUGH:
DATE PATIENT RELEASED TO RETURN TO WORK:
(Please give estimate if not able to determine at this
time)
HAS THE PATIENT: (Please circle selection)
RECOVERED IMPROVED UNCHANGED RETROGRESSED
DISABILITY RELATES TO:
PATIENT’S JOB
ANY OTHER WORK
WHEN DO YOU EXPECT A FUNDAMENTAL OR MARKED CHANGE IN THE FUTURE:
1 MO. 1-3 MO. 3-6 MO. 6-12 MO. NEVER
WHAT ARE THE SPECIFIC REST RICTIONS AND LIMITATIONS AS IT RELATES TO THE PATIENT’S OCCUPATION AND DISABLING CONDITION?
WILL THE PATIENT BE ABLE TO PERFORM THE REGULAR DUTIES OF HIS/ HER OCCUPATION WITH THE ABOVE RESTRICTIONS IN PLACE? YES NO
AUTHORIZED SIGNATURE OF PHYSICIAN
Name (Please Print) Telephone Number
Address Medical ID #
“I hereby certify that the above described information is based upon reasonable medical probability, and is true and correct to the best of my knowledge and belief.”
SIGNATURE OF PHYSICIAN: DATE:
HIP
AA-AUTHORIZATION TO OBTAIN
INFORMATION
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 Child Stepchild Grandchild
I.
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
***If signed by a legal representative (e.g. Legal Guardian, Estate Administrator, Power of Attorney
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
Electronic Funds Transaction Authorization
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
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
DELAWARE:
Any person who knowingly, and with
intent to injure, defraud or deceive any insurer, files a
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.
MINNESOTA:
A person who files a claim with intent to
defraud or helps commit a fraud against an insurer is
guilty of a crime.
statement of claim containing any false, incomplete or
misleading information is guilty of a felony.
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.
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 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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
RHODE ISLAND and WEST VIRGINIA:
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.
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
is a crime and subjects such person to criminal and civil
penalties.
FRAUD
WARNING
NOTICES
(CONT.)
For use with Claim Forms
PLEASE
READ
THE
FRAUD
WARNING
NOTICE
FOR
YOUR
STATE
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Agi Supplemental Continuing Std Form 2015

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Completed 2 July 2020

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