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Get AFLAC S00198CA 2005-2024

H Disability Short-Term Disability Policy Number Injury With Hospitalization Hospital Indemnity Policy Number Deceased - Date Deceased:___/___/___ Hospital Intensive Care Policy Number Life Policy Number Specified Health Event Policy Number INSTRUCTIONS: • Complete Section A: Policyholder/Patient Information. • Have your doctor complete Section B: Physician's Statement. If you are filing for disability, have your doctor also complete and sign Section C: Physician's Disability Statemen.

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