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endobj For disability claims, we will need information from you, from your employer, and from your attending physician. ?NAW
stream 55184 55184 endobj Please fully complete the claim form for the Wellness Benefit. 0000054624 00000 n :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! 2&Tk-bp^c+fLgI$.,d5^! Yku1YRdk^9;TD\;*kl4jYjTa8Xl"SC:fUS)e;!AcrDK#l16`LFaGhEJ;`,G>'H*8^Jr\^>/E?FZ]1S?b
eokV:dNhZMi7O%JW^7S3)e7Na-0A!>>14!l. nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. stream endobj /Filter [/ASCII85Decode /FlateDecode] If this is an Employer Sponsored Term Life Product with your policy number beginning with AFL, please use the forms below. 2&Tk-bp^c+fLgI$.,d5^! ::bl''..9BC;a\$BlT\:t-X,fsW*QN`2e(KL
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Request a quote dialog. DE.V"?h'jom'g4taZ=ggb[Rq9*%"D3_?>DBHcG"%EYhs\A)[02C%,[#:eC])1_\$c?cV\_3\d).P:QmEm*p#YH<04bhGCYr_BRigd-lMFY&qm3!U7+E'.29BdD[1$Xoi)[=&jM/3ntoZ9Yk9SnM:+
Consider filing online for faster claims payment! ;dps@dXdX$3sN65dLrqK;34,XZ>#G6k1;=
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>> endstream <> Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). #18R:]\1;,nqN5j4@OmooAng>Dj7\$6I5WEl9T2tR'\SuV`NS+%%o_@bX'RnWu4:b)*k#n1R(+?O9$>r
If your disability is being extended, you will need to complete the listed Supplemental Claim form. If you are filing for a health screening on your Hospital Indemnity, Accident, or Critical Illness plan for Coronavirus (COVID-19) testing, select Biometric Screening as your exam. ;An6Y?l:#h=mlN1\Er
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<> /XObject << Select the Get form button to open the document and move to editing. (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!AicdVn^"gp(^-oKqo#i"gBOsIn1fK.\PJgLt&^imq7BSJ..gu`g3TNp]lZQ:Q+PSQZ=7bSOhN`;B#7;s#7r)aO+XB?-BFdCkA(+.VnQp*5O$?iSK/`O.QJ'S)/aPDmhO:I1AIuZ^Ves%d@6'UQ5gRhf3BF`kXpaej\IRil\Y_Tp',^\5b3DiW.2X/9G,ZBZNQ1%0jnNTP=-/t4]pG5O*!$Hj%$(Vi!33gU7QS]rt"S4I%1~> A&!R^maAJpBZW3)>! startxref 22 0 obj <> Then, follow the simple steps below to begin the claim process. 0000000009 00000 n 0000054624 00000 n 0000037564 00000 n `JaOS[A]]e$%M7QS4Qo!meJ)_CS:m7V7-aS4FZ1PGi:"6tO9;>TbWc_tC3LGp(
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<> 0000054815 00000 n fKM7f%?5*K:i'+aV_K!?49DLRD(oBT]NI)%kf!BU%-f'rI-kJBX(Gn\B]/9qU,\iQ;,gU.Z@%@^>"[]W:T%89f)q@tlS'SN77! Use the Cross or Check marks in the top toolbar to select your answers in the list boxes. 0000000814 00000 n jPHFW8nlme]HU. endobj 44EBCGZWK1$09&Q#o?-4-.oof+30H,2'QUFu;$7Pkc
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Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the, File a Hospital Indemnity via Fax or Mail, NY - Accelerated Death Benefit Claim Form, NY - Waiver of Premium Claim Form-Initial, NY - Waiver of Premium Claim Form-Permanent, NY - Convalescent Care Benefit Claim Form. 0JTM8HGN-uYUmTOelVf]F4AA)ZISHh>(!HVXe#12]a#X:Z;?uk$a0t'3>1o_N(G1e9TB>Kme4`U:>O6e
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