Fillable Beneficiary's Statement For Death Claim Form (Aflac Insurance)

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Beneficiary's Statement For Death Claim Form (Aflac Insurance)

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Post Office Box 84075 * Columbus, GA. 31993
Phone (800) 433-3036 * Fax (866) 849-2970
groupclaimfiling@aflac.com
BENEFICIARY’S STATEMENT
Failure to complete all sections may result in a delay in processing of the claim.
Any person who knowingly and with the intent to defraud any insurance company, files a statement of claim containing any materially
false, incomplete or misleading information, is guilty of a crime.
AUTHORIZATION: I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medically related facility,
insurance company or consumer reporting agency, or employer having any records or information pertaining to the medical history,
mental or physical condition, evaluation diagnosis, treatment, prognosis, specifically to include psychiatric, drug or alcohol abuse
treatment concerning the deceased and any other non-medical information concerning the deceased to give to Continental American
Insurance Company (Continental American) or its legal representatives, any or all such information. I further acknowledge that the
information obtained by use of this Authorization will be used by Continental American to determine my eligibility for benefits. I
understand that I may request a copy of this authorization. I further agree that a photocopy of this Authorization shall be as valid as
the original and that such Authorization shall be valid for two years from the date shown below.
Dated at ___________________________ this _______ day of ____________________ in the year ___________
Beneficiary’s Signature
Beneficiary’s Address
Street, City, State, Zip
Relationship
Date of Birth
Daytime Phone
POLICYHOLDER/PATIENT INFORMATION
EMPLOYER’S NAME
POLICYHOLDER’S ADDRESS
POLICY NO.
SOCIAL SECURITY NO.
DATE OF BIRTH
GENDER
POLICYHOLDER’S ADDRESS CITY STATE ZIP
☐
CHECK BOX IF THIS IS A PERMANENT ADDRESS CHANGE
POLICYHOLDER’S TELEPHONE NO.
RELATIONSHIP TO POLICYHOLDER
PATIENT’S DATE OF BIRTH
PATIENT’S GENDER
DECEDENT’S INFORMATION
Deceased’s Name in Full
Date of Birth
Place of Birth
Resident’s Address
Social Security Number
Last Occupation
Certificate numbers of this company and amounts under which claim
is being filed
Certificate numbers, amounts and company name of other insurance being
claimed.
I am hereby returning the certificate(s)
☐
Yes
☐
No If no, explain reason
*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)
CAF001LIFE-13-v4
BENEFICIARY’S STATEMENT
A Beneficiary’s Statement must be completed by the person(s) to whom the insurance is payable. In connection with such statement,
the follow should be observed.
1.
If there is more than one beneficiary, all may join in one statement or a separate form will be furnished for each if desired.
2.
If the policy is payable to the estate or to the executors or administrators of the insured, the statement should be
c
ompleted by the executor or administrator, a certified copy of whose appointment and qualifications must be
furnished.
3.
If the policy is payable to a minor or a mentally incompetent person, a guardian should complete the statement, a certified
copy of whose appointment and qualifications must be provided.
4.
If the policy has been assigned, enclose a notarized copy of the assignment.
To prevent delays, please complete the remaining sections and submit the following information:
•
A certified copy of the decedent’s birth certificate or a notarized letter verifying the decedent’s date of birth.
•
HIPAA Authorization (attached) - This form should be completed by the deceased’s next of kin.
•
Certified Death Certificate
Under the following circumstances, please send the additional items listed:
•
If a minor is the beneficiary- A copy of the court order or other documents appointing the legal custodian or
conservator of such minor child’s property and/or estate. (Please note: Legal custody does not qualify as
custodianship or conservatorship over a child’s property for these purposes.)
•
If the beneficiary has died prior to the death of insured- A copy of the certified death certificate of the beneficiary.
•
Date of death:
•
Place of death:
•
Cause of death:
•
If death was due to an injury, please send a copy of the police report, toxicology/BAC report and/or newspaper articles
concerning the circumstances and answer the following questions.
o
Date of the injury:
o
Details of the injury:
•
If death was due to a sickness, please answer the following questions.
o
When did the deceased first experience symptoms?
o
When did the deceased first consult a physician for this illness?
•
Please provide the name and addresses of all physicians who attended deceased within three years prior to death:
Name
Address
Dates of Treatment
Disease or Condition
☐No ☐Yes
☐No ☐ Yes
•
Was deceased disabled at the time of death?
•
o If yes, as of what date did they become disabled?
•
Has the deceased at any time been confined to a hospital?
o
If yes, please provide the hospital name and location along with the dates of confinement and condition treated:
Name
Address
Dates of Treatment
Disease or Condition
AF001LIFE-13-v4
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
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
EFT Form 2016
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
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.
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 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.
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 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.
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Beneficiary's Statement For Death Claim Form (Aflac Insurance)

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Completed 18 July 2020

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