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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.