Get Aflac S00198 2008
Pplication for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and subjects such person to criminal and civil penalties. Policy Number: Policyholder Name: Patient Name: Date of Birth: SECTION B: PHYSICIAN’S STATEMENT Please answer each question COMPLETELY. Physician’s Name Phone Number ( ) Fax Number ( ) Mailing A.
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