Accident/Hospital Indemnity Wellness Benefit Claim Form
To file your claim online, upload documentation on an existing claim, check claim status or get paid fast by
signing up for direct deposit, register on Aflac.com or download the MyAflac mobile app.
➣ Benefits of filing your claim online include faster claim processing time and receiving claim
communications by email.
Please read all instructions and complete the form, failure to do so could delay the processing of your claim.
Please check your policy for specific details on this benefit.
• Do not include receipts, statements or other claim documentation with this form.
• Do not write on form except as instructed.
• Sign, date and fax or mail the completed form to the Aflac fax number/address shown below.
• Use black or blue ink only and print legibly when completing this form in its entirety.
• Mark only wellness exam boxes for test(s) and/or treatment(s) received.
• Failure to complete all sections may result in a delay in processing this claim.
• Some types of tests and/or treatment listed may not be covered by your policy.
Please keep a copy of this completed form for your records. Please print a separate form for each additional family
member or call 1-800-99-AFLAC (1-800-992-3522) to request additional forms. Claims for all other benefits covered
under this policy must be filed separately using the claim forms available at aflac.com or by calling 1-800-99-AFLAC
(1-800-992-3522).
DUCK
American Family Life Assurance Company of Columbus (Aflac)
ATTN: Claims Department • 1932 Wynnton Road • Columbus, GA 31999
For information or to check claim status, visit aflac.com or call 1-800-99-AFLAC (1-800-992-3522)
Claims may be faxed to 1-877-44-AFLAC (1-877-442-3522)
CW061999 Page 1 of 2 02/14
Policyholder Information:
Policy Number:
Patient Information:
Last Name Suffix First Name MI
Date of Birth (mm/dd/yy) Telephone Number where we can reach you
Home Address
City State Zip Code
Last Name First Name Date of Birth (mm/dd/yy)
POLICYHOLDER/PATIENT SIGNATURE FAMILY RELATIONSHIP, IF NOT POLICYHOLDER DATE
Physician's Street Address
Physician's City State: Zip:
Physician's Name
Physician's
Phone
Number:
Check box if this is permanent address change.
All Fields are required.
Annual Physical
Ultrasound
PSA (blood test for prostate cancer)
Pap Smear
Blood Screening
Immunizations
Eye Exam
Dental Exam
Sex: Male Female
Relationship: Primary Policyholder Spouse Dependent Child
M M D D Y Y Y Y
American Family Life Assurance Company of Columbus (Aflac)
ATTN: Claims Department • 1932 Wynnton Road • Columbus, GA 31999
For information or to check claim status, visit aflac.com or call 1-800-99-AFLAC (1-800-992-3522)
Claims may be faxed to 1-877-44-AFLAC (1-877-442-3522)
CW061999 Page 2 of 2 02/14
Accident/Hospital Indemnity Wellness Benefit Claim Form
M M D D Y Y Y Y
Pap Smear
Date:
M M D D Y Y Y Y
Mammogram
Date:
Treatment and Physician Information
Mammogram
Flexible Sigmoidoscopy
/
-
-
/
/
/
- -
Treatment
Date:
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.
The Provider listed above is authorized to validate the information I have provided.
