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Get Cancer Annual Care Benefit Claim Form

DUCK CANCER ANNUAL CARE BENEFIT CLAIM FORM Please read all instructions. Failure to follow these instructions could delay the processing of your claim. Your Aflac Cancer policy pays one Cancer Annual Care Benefit per year up to five years following the anniversary of the diagnosis of internal Cancer for any Covered Person surviving Cancer. Do not include receipts statements or other claim documentation with this form* Do not write on form except as instructed* Please sign date and mail or fax the completed form to the Aflac address/fax number shown below. Please use black or blue ink only and print legibly when completing this form in its entirety. Failure to complete all sections may result in a delay in processing this claim* Please keep a copy of this completed form for your records. Please print a separate form for each additional family member or call 1-800-99-AFLAC 1-800-992-3522 to request additional forms. Claims for all other benefits covered under this policy must be filed separately using the claim forms available at aflac*com or by calling 1-800-99-AFLAC 1-800-992-3522. CW91264CAC FL Page 1 of 2 American Family Life Assurance Company of Columbus Aflac ATTN Claims Department 1932 Wynnton Road Columbus GA 31999 For information or to check claim status visit aflac*com or call 1-800-99-AFLAC 1-800-992-3522 Claims may be faxed to 1-877-44-AFLAC 1-877-442-3522 02/14 Policy Number Policyholder Information All Fields are required* Last Name Suffix Date of Birth mm/dd/yy / First Name MI Telephone Number where we can reach you - Home Address City State Zip Code Check box if this is permanent address change. Patient Information Sex Male Relationship Female Primary Policyholder Spouse Dependent Child Physician Information Physician s Name Physician s Street Address Physician s City Zip Physician s Phone Number Tax ID Number I verify the above mentioned patient is currently under my care as of the date I have signed this form* Date Physician Signature Any person who knowingly and with intent to injure defraud or deceive any insurer files a statement of claim or an application containing any false incomplete or misleading information is guilty of a felony of the third degree. The Provider listed above is authorized to validate the information I have provided* POLICYHOLDER/PATIENT SIGNATURE FAMILY RELATIONSHIP IF NOT POLICYHOLDER DATE. Do not include receipts statements or other claim documentation with this form* Do not write on form except as instructed* Please sign date and mail or fax the completed form to the Aflac address/fax number shown below. Please use black or blue ink only and print legibly when completing this form in its entirety. Failure to complete all sections may result in a delay in processing this claim* Please keep a copy of this completed form for your records. Please use black or blue ink only and print legibly when completing this form in its entirety. Failure to complete all sections may result in a delay in processing this claim* Please keep a copy of this completed form for your records. Please print a separate form for each additional family member or call 1-800-99-AFLAC 1-800-992-3522 to request additional forms.

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