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REQUEST FOR DELETION Please use blue or black ink only and print legibly when completing this form in its entirety. American Family Life Assurance Company of Columbus Aflac Attn Policy Service Department 1932 Wynnton Road Columbus GA 31999-7000 For information call toll-free 1-800-99-AFLAC 1-800-992-3522 Name of Policyholder Last Name First Name MI Policy Number Policy Type Date of Birth Person to be Deleted Sex Male Relationship Title Female Insured Reason for Deletion Spouse Divorce Child Death Request Date of Divorce/Death/Request New Policy/Contract Holder s Full Name Birth Date of New Policy/Contract Holder Billing Name only applicable if policy on payroll New Coverage Desired Individual One-Parent Family Two-Parent Family Named Insured-Spouse Only Policyholder s Signature Date Is this a Section 125 account If yes you must have the Plan Administrator s Signature. Section 125 Account Approval Date Section 125 Plan Administrator Signature Form H-L0046 HL0046. 12B. Keep a copy of the supporting documentation and this completed form for your records. Sign date and mail the completed form to the address below or fax to 1-800-448-8922. American Family Life Assurance Company of Columbus Aflac Attn Policy Service Department 1932 Wynnton Road Columbus GA 31999-7000 For information call toll-free 1-800-99-AFLAC 1-800-992-3522 Name of Policyholder Last Name First Name MI Policy Number Policy Type Date of Birth Person to be Deleted Sex Male Relationship Title Female Insured Reason for Deletion Spouse Divorce Child Death Request Date of Divorce/Death/Request New Policy/Contract Holder s Full Name Birth Date of New Policy/Contract Holder Billing Name only applicable if policy on payroll New Coverage Desired Individual One-Parent Family Two-Parent Family Named Insured-Spouse Only Policyholder s Signature Date Is this a Section 125 account If yes you must have the Plan Administrator s Signature. Keep a copy of the supporting documentation and this completed form for your records. Sign date and mail the completed form to the address below or fax to 1-800-448-8922. American Family Life Assurance Company of Columbus Aflac Attn Policy Service Department 1932 Wynnton Road Columbus GA 31999-7000 For information call toll-free 1-800-99-AFLAC 1-800-992-3522 Name of Policyholder Last Name First Name MI Policy Number Policy Type Date of Birth Person to be Deleted Sex Male Relationship Title Female Insured Reason for Deletion Spouse Divorce Child Death Request Date of Divorce/Death/Request New Policy/Contract Holder s Full Name Birth Date of New Policy/Contract Holder Billing Name only applicable if policy on payroll New Coverage Desired Individual One-Parent Family Two-Parent Family Named Insured-Spouse Only Policyholder s Signature Date Is this a Section 125 account If yes you must have the Plan Administrator s Signature. Section 125 Account Approval Date Section 125 Plan Administrator Signature Form H-L0046 HL0046. 12B.

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