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Get Aflac Form 513270

877. 44. AFLAC 1. 877. 442. 3522 S13270 Page 1 of 3 07/11 Policyholder s Name Patient Name Date of Birth SECTION B EMPLOYER S STATEMENT EMPLOYER S NAME PHONE NUMBER FAX NUMBER MAILING ADDRESS CITY STATE 1. First date of disability / / 2. Has the policyholder returned to work If yes is the policyholder working Full-Time Part-Time If the policyholder is working part-time date he or she began part-time / / Date returned or expected to return to full.

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