Loading
Form preview picture

Get Z06197ad

Was performed. Please check your policy for specific benefits covered under your policy. Do not write on form except as instructed. Incomplete forms cannot be processed and will be returned. Please do not fax this completed form to Aflac. Mark only wellness exam box es for test s that you had performed. American Family Life Assurance Company of Columbus Aflac Attn Claims Department 1932 Wynnton Road Columbus GA 31999-7251 1-800-99-AFLAC 1-800-992-3522 aflac.com 1-800-SI-AFLAC 1-800-742-3522 en espa ol Z06197AD NJ Some of the tests listed may not be covered under the Wellness Benefit of your policy. DUCK ACCIDENT WELLNESS BENEFIT CLAIM FORM Please read all instructions. Failure to follow these instructions will delay the processing of your claim* Do not include receipts statements or other documentation with this form* Your Aflac policy provides one Wellness Benefit per policy year. To receive your Wellness Benefit complete the form by following the instructions provided* Please keep a copy of this completed form for your records. Claims for all other benefits covered under your policy must be filed separately using the appropriate claim form* If your Aflac policy also provides a Mammogram Benefit please mark the appropriate box and indicate the date the mammogram was performed* Please check your policy for specific benefits covered under your policy. Please check your policy for a list of covered wellness procedures or call 1-800-99-AFLAC 1-800-992-3522 for a Wellness Form specifically tailored for your policy. Please use black or blue ink only and print legibly when completing this form in its entirety. Keep a copy of the supporting documentation and this completed form for your records. Sign date and mail the completed form to the Aflac address shown below. Policyholder Information Middle Initial Policyholder First Name M D Y Policyholder Last Name ZIP of mailing address Birth Date Policy Number Patient Information First Name Relationship Last Name Sex Primary Dependent Child Spouse Male Patient Female Wellness Exam Treatment Date Treatment date must be provided* Annual physical Blood screening Dental exam Ultrasound Immunizations Flexible sigmoidoscopy PSA blood test for prostate cancer Eye exam Pap smear M M Mammogram Physician Information Phone Number - Name Street Address City State ZIP Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. DUCK ACCIDENT WELLNESS BENEFIT CLAIM FORM Please read all instructions. Failure to follow these instructions will delay the processing of your claim* Do not include receipts statements or other documentation with this form* Your Aflac policy provides one Wellness Benefit per policy year. To receive your Wellness Benefit complete the form by following the instructions provided* Please keep a copy of this completed form for your records. To receive your Wellness Benefit complete the form by following the instructions provided* Please keep a copy of this completed form for your records. Claims for all other benefits covered under your policy must be filed separately using the appropriate claim form* If your Aflac policy also provides a Mammogram Benefit please mark the appropriate box and indicate the date the mammogram was performed* Please check your policy for specific benefits covered under your policy..

How It Works

legibly rating
4.8Satisfied
47 votes

How to fill out and sign false online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Experience all the advantages of completing and submitting legal documents on the internet. Using our service submitting Z06197ad usually takes a matter of minutes. We make that possible by giving you access to our feature-rich editor capable of altering/correcting a document?s initial textual content, inserting unique fields, and e-signing.

Fill out Z06197ad in just a couple of moments following the recommendations below:

  1. Choose the document template you will need from our collection of legal forms.
  2. Choose the Get form button to open it and move to editing.
  3. Complete the necessary boxes (they are marked in yellow).
  4. The Signature Wizard will help you insert your electronic autograph right after you?ve finished imputing information.
  5. Add the relevant date.
  6. Look through the whole template to make certain you?ve completed everything and no changes are needed.
  7. Press Done and save the resulting document to the device.

Send your new Z06197ad in an electronic form right after you are done with filling it out. Your information is well-protected, since we keep to the most up-to-date security criteria. Become one of millions of happy users that are already submitting legal forms right from their apartments.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Norton logo picture

    Norton Secured

    The highest level of recognition among eCommerce customers.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.