Accidental Injury Claim Form Aflac In Clark

State:
Multi-State
County:
Clark
Control #:
US-0022BG
Format:
Word; 
Rich Text
Instant download
This website is not affiliated with any governmental entity
Public form

Description

The Accidental Injury Claim Form Aflac in Clark is designed for employees to report workplace accidents promptly and accurately. It requires detailed information such as the name of the injured employee, job title, and specifics about the injury, including date and location of occurrence. This form is crucial for initiating claims with Aflac, ensuring that employees receive necessary medical benefits quickly. Users must complete the form within 24 hours of the incident and forward it to Human Resources, facilitating the claims process in a timely manner. For attorneys, paralegals, and legal assistants, this form serves as essential documentation for personal injury claims and potential litigation. It supports the need for thorough reporting and enables professionals to gather necessary evidence. Additionally, owners and partners in businesses can utilize this form to ensure compliance with workplace safety protocols and to manage employee health benefits effectively. Accurate completion and submission of the form are vital for protecting employee rights and ensuring they receive appropriate support.

Form popularity

FAQ

Accident Claims Checklist. Z2201218R1. Identify your policy. Policyholder's address. What you need to file a claim. HCFA 1500 (non-hospital bill). ER report or operative report. (Please obtain the supporting documents for the corresponding benefit.) ... Proof of services. My Claims. MyAflac® helpful tips: ▪

Accident Claims Checklist. Z2201218R1. Identify your policy. Policyholder's address. What you need to file a claim. HCFA 1500 (non-hospital bill). ER report or operative report. (Please obtain the supporting documents for the corresponding benefit.) ... Proof of services. My Claims. MyAflac® helpful tips: ▪

Q. How long do I have to file a claim? A. There is a one-year timely filing provision in your certificate.

To file a claim, simply select the appropriate claim form for your specific product and mail or fax it to us at the address on the form. Download the form. Fill it out. Send it in to: PO Box 60676, Worcester, MA 01606.

Claims for all other benefits covered under this policy must be filed separately using the claim forms available at aflac or by calling 1-800-99-AFLAC (1-800-992-3522).

POLICYHOLDER'S EMAIL ADDRESS. POLICYHOLDER'S MAJOR MEDICAL INSURANCE PROVIDER. MAJOR MEDICAL ID# ... POLICY NO. SOCIAL SECURITY NO. STREET. CHECK BOX IF THIS IS A PERMANENT ADDRESS CHANGE. ZIP CODE. PATIENT'S NAME (PERSON WHO IS SICK OR INJURED) DATE OF BIRTH GENDER POLICYHOLDER'S TELEPHONE NO. RELATIONSHIP TO POLICYHOLDER. Self.

Q. How long do I have to file a claim? A. There is a one-year timely filing provision in your certificate.

Common Documents: Proof of Insurance (policy document or cover note) Engine number & chassis number. Accident details (location, date, time) Km reading of the car. Duly filled claim form. FIR copy (in case of third-party damage, death, or bodily injury) RC copy of the vehicle. Driving license copy.

Trusted and secure by over 3 million people of the world’s leading companies

Accidental Injury Claim Form Aflac In Clark