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Get OH Aflac S-13270.1 - City of Columbus 2008

Disability due to a Sickness Disability due to Pregnancy / Complications Accident Policy Number Disability due to Cancer Short-Term Disability Policy Number INSTRUCTIONS: Complete Section A: Policyholder/Patient Information and sign the claim form. Your physician should complete and sign Section B: Physician's Statement. Your employer should complete and sign Section C: Employer's Statement. Policyholder Information (Please print.) First Name Initial Last Name Mailing Address City .

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