View details, map and photos of this single family property with 5 bedrooms and 3 total baths. If your disability is being extended, you will need to complete the listed Supplemental Claim form. endobj ?f48_G,BN0p=/>&*)"gUTVU[Y>F[!H0S$cH]UJRYpFnh6'Ae"7a6i,,,Lbtk3(JMM]r0XUgZr>L@0I'i endobj mQYc=\E9,ERP]c]=8bqqqY%CP/fB'k8=no-Ws101`o*'eZs]oap*qMF <> '1L#-Ne#BOUYn.SL> trailer<> QQZnEET3`^=L@5Inq5fkUd?/3Y2`;02=IqDob^'R&m,FG.6*VIW,-bt2>#UYOZJj>;fU1^9uM()U8*1b PolicyholderInformation:This*denotesarequiredfield. endobj !^`!O2!InjU(e3U7YceUPSbUm,".#RY6kVt+9Vg5'L]Mt+EU">H4*U`'^6l6 "DFX!Fen1$B29'W4#sWKq Health care provider includes . /BaseFont /Helvetica-Bold All forms are printable and downloadable. jd*ZcXe"_QS4SaSM0H8\:kGm7EGchf:.,NK]?.0?7FYh&?aae5>4\THpn]0*9A8N ri$-h1/j[uMOPf3_2gQ%+)4Tt@BXW(2=KO%3;tVmZjc93ISZ#id:hb)o".^eIJY!Pf"3t`9hfK3>.oW& endobj HQ$ujRc"9@)AC83@/u';(.AU@8h[,dM5@MBi91i8@]+f5P8hFJ11.%Ec:Brs4lZA';_labWMQK7-EQHe 9 0 obj "\1ceiPob[!+@J3(3TJ)YX)OUj[W9&;I:dYZ=kc)4eebY'g`kA>>[&O][obn/UEdfgRXrat28;.HM:HQa#NGoYVo#="o%! 0000037564 00000 n *#*-ScS*/MMA_!%)m!2N2g5V( endobj !G5'>m!$kI`%E,=&c9e1!`-(ln6%1Abq7/PK2;m`V,'D51([Fj "tZ 0;p5g%:Gd\>Io0dB\q^f8G>h/i$&$eAg8lGgN!bHFN/%]=BXD&^?mb,/u7t)rbDTL)pZ8Q"RdB*(8=i? trailer<> Rf;iu7gGe[$chW^;W6Fl=BqZ%6KIFZ'HNb5)TaYYGG:'$r`) Apply to Behavior Technician, Para Educator, Family Service Counselor and more! health plan (including CAIC or Aflac, with respect to other CAIC or Aflac coverages) or health care clearinghouse that has any records or knowledge about me. !o5ERV47$k+S(!Xa"PN!I9]Y4"VHDRe8O[\PP>C\n_[q%@(=l5'/%#n49 endstream $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K &>7[>d7(qqN/lSW8,9((\,+tAibO:g1>Tl'K;D\HUqeC^#X0pPUXu3oeqYppd\O0nI(-OoF3]X=)@;7_ 0000000446 00000 n endstream endobj Request a quote dialog. <>stream Please fully complete the claim form for the Wellness Benefit. 0000003079 00000 n [P'])96k0r/j-O-5R.B+?Ujtp8t.Wa^\9uALh!R/l:Z3W3Fi9-eo;Q)?QN/coX1HH='4^ ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R You can now make your claim online by accessing your online account. 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Aflac Continuing Short Term Disability Claim Form Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf Please note: The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee's Form W-2. ^$F!_M^D.n0(qARn(aE/AgY,iIM9"8CcNDqjSN*8m)"S@.f==Xc1]GcbA-_LZ\:A:pe2tj U;s(7Es'Hq&:@a]^0oUGCJa3R7thK`//"XdS%5f,bl:[\>V0EGJX9:R[P$&(L2fO4E"!r*bnZA.0JbrSKY5@2H. N8EYJ/rdd(..BX8/1[!lhITlJFmO/CsZ%j/>QaJ13;:-PF0g Claims are subject to underwriting . <> 25 0 obj @t8o'GZ4D)sCs51c+#T4\n6>"b>\hV.b\NHH 2@Aq[=+(TD3oRc#`>K/0ZNjU%/:30? TLFC\4aS)n5C^j*@4%"P0VVa9rj(. 0000000326 00000 n Dental and Vision plans are administered by Aflac Benefit Solutions, Inc. Select the Get form button to open the document and move to editing. ?&2QmV4C.$NuL;0P(Z7tk6M Gb!'5m[/fJB\_$r.pF?nb0?9.GNU`POZa=?bcjAXQ5kBDO7EHm>6&%47Ab&pW\\Ep0DVbs4$N;\XPZ>cd==.mQbW>ZXE(h&hj!?>RE;`-=j0]K(7>2TZ2c#qP2TZrnnVO>AAO\2\dZ]BV5lN<2g@`o#75u,Z^-1@eCMYZY`nV9iX]Jk15[r)/_I8dD(4^c,bTd,',#!J7^rL)<3a8P7fG%*rf%Dr0X9k_#\a>h%ENsu1N_I/E6"$"4aO%gkZ#_P8u%,_DD4Z3`,&-G'RNJo*@\gVBC#dISL`OXs`X"2c\XYOgQMjo(nU9j@@I>:$?-SG%p\5>K8mf'`2n5g](hjREP0cIi=DlJG%CduFYJX&b.fJg%;BE/2\Y7`WHp'nr&%:J'Y"Od>X7ZKtp1A2/F(Cd$FjNX24)>aWHAi,$d!uihMX'(n_)L`HY6h*Ya>%R%`kI!@VZ@Kj*91XAll1b#)Sj(43C0*ZDYVHW.o&^]8^cs$b>tO5/3)s#"+[I40fCCO0u2)j*3e@/a);GiEC,QcYi&n:D@TcfYcBYeX>jFB"0g]k[qcIUEDh\sY`P3V$amn](*)ZhblK=iC]sei38!J\1:'Sm^g=9F1G?^5X*UTD.c8Kg>?CNpfj;t*;*+5-3+-1$][#p+$s7LY3ds$(WS^3ipt1n?4gpo(-)4hZ]5TSD1c"b62Ae,uI=ht5%%pur?]C"mK+/"n@,G@E!%Tm_Z('e6`@=LQJX>m2u!EdFdln=`n_1KT(Jdtn&@OhFd_-qh%AS.4e_"nG>AmU@I`/XL)S*AH60oN#\=,_M)mR[KZ"p#@QKTXhSQoBW6Pc2r1abgMO4mbWZJ_P.S0Z?CC27h1I4*Xt]'k^P`c1tChMX"]cTFjUN>O%@eLs@rgmWT?ci5AXtahm=GCI0lG41Vu%ET![Pf]&aI:B+JKG^84P$0u2CD+0?/0su!u;km^rug0:2"VI(*%/+bQ/)HNQVs0JlC_#J`D*lKqGe.5CT5W%::0+m=,"tDhT:Jf.Zq_h(jA)][.]!1gIc_g$e.NIY7[Dn[]g&+*Dc(B:jSF2;0_UcSO=hWJLHLeZ$&=Ibr9.GHm'mXS3P2Ek.5Ya!YtUFO)#kgZ.eZ`LC0e]4]aW"'asKdg_Z"5EE^C=)[U)8)55iHZq2>kKE;Zj.Do+X/DSW[g,Q>hSOSQ$%5h_?(@[q&hh1R=9+/)8;"A^Hn>PPi5t$eN5g`uORs-`,rNBc0.X_)BIVn/qs?1NU@,SCi]^G`[P0TK1pr%^qAZJ4DVn/T'u"#MW0u^k8/G"%kaRF,8qKUN? Please choose "Individual" or "Business.". 5]mS)I&\m'[NsCj]sr@0El\`]Uq+.S367pgfd2I2(=P['dU+EV"7XqK'c7K%if?fQ]VP )toiFe(5W*JmS'IeRpMhRM\E^RfC)>n7:/sPgsY5E^.`.P>\/9SK;2 Manage your account, submit and track claims, setup direct deposit and more. Log in to to your account or Chat with us. X3$l$UUC.Q8bG%FB^qod-T(^7g7U9j!? *PolicyNumber: / / - --PatientInformation: *LastName Suffix *FirstName MI *DateofBirth(mm/dd/yy . 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No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . /2R!i5j&PBRjtAnemGT^T>r)/aH+##c99WL>k&k>=:> :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! [W_J1(2pZ1HC$V;V*/7\3N-"m8ACA6(\G4_j7tLZo4PDu:9kltQ:qtrOFJei`3u25)_cfnQ2M,M>*2Sb (q4#=jL^)VnPi.3J&P`.^'?D&jk\gq++JIRRP;p/j8Q)Z,M')M)EjWNe^:g;JhU)j"t=W%Q@J=*Le%l7VZbQ,Dgs8NZs/^) 19 0 obj No Yes Isdisabilityduetoaninjury? 0000000446 00000 n << 0000035380 00000 n Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). 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(V.ea8oM1meVG5&2$R&VHdRmbM`,/jQ'iTTlk_NLi7Pu8>hqB>F6,at#]$=1\UL'_o 0000000000 65535 f 19 0 obj "kt65Ko1TNq1+;X4?fH1W0SbI2D-F(6cs2(!E?1oM!HZ/`bJ.Cb4@4gWrBVNX,G01o;?NA0^%)?aS>EJ /Type /Font $d"'aL\l#A%IE5_YS4O4h)$pN261/3.91=eY! DE.V"?h'jom'g4taZ=ggb[Rq9*%"D3_?>DBHcG"%EYhs\A)[02C%,[#:eC])1_\$c?cV\_3\d).P:QmEm*p#YH<04bhGCYr_BRigd-lMFY&qm3!U7+E'.29BdD[1$Xoi)[=&jM/3ntoZ9Yk9SnM:+ trailer<> endobj Gau1SB38*gei()N&>^6. Please provide all information requested on the Insured's Statement portion of the claim form. 93^8SlqmQZ!1De"\u*GfeLd;np?nPWYSd67)d]ch=uD%XiFi:dZhC'MhDK8OlZ2*YHmB.O$)Wh[*"R,, #uY.o`Vd[Bd.YT[///3UJY[r*;n,NhjZnQjdJ7=`r$)Ri)3:i(@X2#3?N.HcWa:.*$kP? stream YKROsZ>WYNLd_t?65*\J,Z?QVE?JeNB#Lrk^]8>,3&l. <> ;Y'TZ`#NiWQ <> The Disability Claim Form (Aflac Insurance) form is 8 pages long and contains: Use our library of forms to quickly fill and sign your Aflac Insurance forms online. POije23\6G%qCTitHV>Xor, Aflac, excluding psychotherapy notes, and including, but not limited to, . 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Life claim forms for the state of Illinois must be obtained by contacting Aflac Worldwide Headquarters at 800.992.3522 to have the appropriate forms sent to you. endobj Aflac may include American Family Life Assurance Company of Columbus, American Family Life Assurance Company of New York, Continental American Insurance Company (marketed as Aflac Group), Tier One Insurance Company, and any other affiliated companies (collectively, Aflac), as applicable to the entity from whom you receive insurance services. ]aL:-7m>f%Su%B7MshR`^)f!O)AO 2"3sWA960?8;mmK#ZE2_=#C>QJ%q+@gg/`.\j'lY3GBQ_ecS2/`]F/b3$3maOCefRcJ`5!g@1,GaV\/9 @oGDmsuR- 24 0 obj s(a2"ShqZon2tUR"gff@QgRi&=8T@kgq-(JZ&gl35W-8HGs$[[cMe HQ$ujRc"9@)AC83@/u';(.AU@8h[,dM5@MBi91i8@]+f5P8hFJ11.%Ec:Brs4lZA';_labWMQK7-EQHe endstream endobj Gb"/l>AkOk&]_Z/^,64CCgQh(QQim(`'@6(M1VCS?Ymokm)Y?"923o3hrP9g4Yu*CcB6B*!?;6YT@s1*_r:*jjIVWN?8SPT[V>.M20U,P9l'4iI6TPY-]L!#f3%M(`,YCfUG&+3=,h@oh'%%R8_;#D97$7DPAU-\'4cMbSmaD1quDo:PhC8FAQ_/2XZE4Kg#d',UPm7ke>cGNcuWsA1Re6L<8TPh=9[*Pk3kf]HG?:]j+f^e0da8lF5rcV:E%B=r3G;%R(Xf":ZPhD;HI=o2=W1:skhAOSf)4$6[Y*hA_qQ>#XK+S'ZUkOIKD*iLBqMO1XS"!cLPYd()UE9Lm2lr6Mn03Uc=D9cmg9ZFLR'j#lTAS?p0fFMITB#ShK:pcr`bu\*p_7fncO=H:Cg))Dh,V>4bK>oW$PT7aee,0TKjD0nWW>XIsXWdMeY)H^W"J?KP[.,0T5VP[&"V-R*m\g;oH$Xg-3^E`2UO>b:S!S#%Ni>r1U>7W]WVl%FBJ6EJLK\e5S/p'%Rhg`ig(XQcq,`dM"Z"a`kcZ-'(jE_+^$?7s6^cGj474dI*df2J-e5q=Y_1b16H?P]03X?3K>qnsh^!G`9eSL__s6U1M*9Teo45)s'E#TeBH)kV0Og)S^AO+J(2F[da5RA>ICW7:^P&t'LLAnd0HKr&IpsIn8SeU(:Jc=*pS?k-99YCErn>UJX-`Hn%(aqln*&$XIcANS4VpU[QLj]G!;#@EAKq^@j,u;`/,(/Na!g5q"Yh65\"D,!aB.Em\'n/8"7*<31JeCqa`mMJ:h^-@Y+&*%Hi'pHjq[(V+Huac?`=P/n;ZtVYhK&jU4+P;,;Li0RY7*b9.,B=i>Eeq&&>XEt+0g%csST^gUX`O)f4L?@mpN=*2KGID@n!ahWqW<0.bbeua0:q(o7]2r0OVPUZgknmZaeqoclXGYUp'!2bS=sHp[\G[PG!Smtge^H`:p@^73,cnK$pco"N52fZ7k,?t_TBa6[Yo38a*bPjO'L>&jO>C.hg#O#*qQR%MfmPB/pb=.ds3hbk[@d1B`!QLOun.$sgs3XfN'9kHM]j^-B:=S5hBb`)3Y[+?"%4"O*G7.WL:[M7VEor0!>;%F[GQFZUW-817ADTaR](EM)4B>C4br^N)Q@KkkpNbQ$O`Ai!OQG#u9I'pD\EjH. 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. 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