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Aflac lets you provide your employees with outstanding benefits without costing you a penny. )S.%6`+GjIZj](Q#<=c@2$Z7dM/>T[*ou6=\86%`.6Tf9_%C^ECG2N>a#UsXf8l(9b*mV6r!V.s)b^~> )S.%6`+GjIZj](Q#<=c@2$Z7dM/>T[*ou6=\86%`.6Tf9_%C^ECG2N>a#UsXf8l(9b*mV6r!V.s)b^~> 2#Uk88j6F;!LPJCYg?_VnT>DO7>((M$tI28>B]"L9/3#3R1],d$6!$JJRKV2m(tG_Q]-T()Va>`2T]>l;eK>s(U,g-lu^? 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A hospital indemnity claim requires supporting documentation for review of benefits, itemized bills showing medical treatment dates and diagnosed conditions, hospital admission and discharge papers for inpatient hospital admission and confinement benefits, pharmacy receipts for prescription drug reimbursement, and a signed and dated Authorization for Disclosure of Health Information (HIPAA form). startxref 18 0 obj If you disagree with a claims decision, you may submit an appeal citing supporting policy provisions. endobj 01Kfu^/nVO+L(Jdq73kWrp8S-B^0`qh,U[o.OS(9*S//rm]sB[#0$Ikq. <> 17 0 obj <> Aflac Group Policies: <> /XObject << 0000055102 00000 n _^7`jFRJiik^>[sr;K_R=oP`RhjIDn7[PIg5,_,"obk"U42[,7b`:kTqB'Do)liYcA9l:=H+qjE). $s?SXVcf%'C4RJ(8`-)k.!R/tmOC4@"`:#!%j`_M[6BFOHB#O$NY5c1rOEh=kBspt>`NP'>;a[EcIDPt ;]2"WH3RN-IY-eA348fl;R6]T4%O*^emkHfI8Di4T'&!Ns\94;%b File a Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claim, File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company Claim, File a Universal Life Insurance Claim underwritten by Trustmark Insurance Company, Do Not Sell or Share My Personal Information. 26 0 obj 2"3sWA960?8;mmK#ZE2_=#C>QJ%q+@gg/`.\j'lY3GBQ_ecS2/`]F/b3$3maOCefRcJ`5!g@1,GaV\/9 ;:9bBtb9H]qk\bkhPfIu$"+1TVJFo3OYhdrtnn;;,mTF]?KG*]5oEoE,[rmic= 0000000563 00000 n #18R:]\1;,nqN5j4@OmooAng>Dj7\$6I5WEl9T2tR'\SuV`NS+%%o_@bX'RnWu4:b)*k#n1R(+?O9$>r stream 18 0 obj nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. 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Simply click Done to save the adjustments. endobj Also, if you are filing during the first year of your coverage effective date, we'll need you to provide the information requested on the, File a Hospital Indemnity via Fax or Mail, NY - Accelerated Death Benefit Claim Form, NY - Waiver of Premium Claim Form-Initial, NY - Waiver of Premium Claim Form-Permanent, NY - Convalescent Care Benefit Claim Form. 0000000446 00000 n << /Count 1 /First 18 0 R /Last 18 0 R >> <> )lM~> Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F trailer<> In NY, self-funded plans and absence services are administered by and insurance is offered by American Family Life Assurance Company of NY. ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; 5 0 obj [lXipns%dYmtWgT45TNAg1!L7&LsF1AVS8,9_:a+p=0JYXs63uqK)DZMF:+=COnscG]5l!0l_(jD#HTn3T/Nq3TXul_X>mcZ"L&H2kUp].^k.4,_Aof>Ug=,=b3fQf+d*!6h*m;*04i'C0/[p+\Sgs.&*IjrlVLg~> <> :mWZojRr@ZVSY:Chrj]K$+%1kYl-LbN@(bf_KEb@@>[qFlJ*LgO_kj'#$nA/j,nt 20 0 obj Gb"/,=``@V')jD/9@r'LI-A9Cs4QG6aPLKNd:@s1MX5It9Jnu*B"qkR+QHs<2n)%/\Xan`a,N@6*ingN'+f$>Yo4]C!mu:p`lCe=FLB/(I,"jXamHKJNR+)Gl0L9$(Q$m:^j,14/`h-mD]X`XMK+=Y,,E.#`="+f8AJYrKUGA5Q"McHIugr&gV)sipH;3V;[q7F*GJY%abm(8>b!Y>#S?Q?en;S)"OEiMWIE&0@qh;EHk*_:=;gW4*><30$L0fSkD:d)2[Y8SYpcUZmVX";D!VFF#NjUnu/i=(eN%U3gqf'WI/NZX5pMY'?GQ)r4VCNI>8uDZ9$#H/kaQcLFj`bUB3^t!`Q:uaAT(ea1%WFIpS6Ag:?>H$75dihDjh[BEL"?jPA)pe]F.YplX)@3j98ARtS-K?QMb7,!]b.D>VpVJ$.D,Cgnh]1J7T(AtopjVlaB^!.A26henEG&.OY;@Iq.U(;Viu(HKO$.\K*8Lk^]!(LVMX-[0L]OWdQ5O?*Qg6:M)P^@ai,(^_E!:Iq@eTnj3uRVpK]@Or/E+[-a7Dp>u^OF%E]LIm[rs(u=5^p\I80PCZ8,!eM\4J4j18:dSOVOU6cZ[#)7UXXs5pjV;9['\gDTUS6EdKO#QZhq:bWR?R:@4Y8CQ1h]L`j6s02no<6g[7i(GO`Q-$7mHN=/n:Gf.H@)J0"*O&:6O.K18Wn33WAg;s,d1LUJO%Lfo4ld_7CG_g\RF[0d-qmdP5,$mH-h*Ula*D+fdn$e=XEOMub_:t*%ti!>W,FhJC&3*L=^)sJ%F;NO"C9[kluU]cc98X)>X"A2]7JD"#9Q(eSSX<2hiWOMu3c*3Cl#A.:WQKCi-LU%^3>#DKnSAK:Z0%R4F:$c,fB*LTO?$D[Y9m;(K*!bMU6i&L`h@5#$fCr!VJ)*$ApDE(Iaqq9p'5JJ$OWoHV-lnT.-#2ji?i4+(+-+=[%\t6Q3*F98'B&T>Z*VMs7:^kaickW#fPk2Q*ZN$"Y`Nr/T3i]pS_d'/qC"V#!L/GaW.3?1m>ardXNjcoog4djTG`ic)$u]?!eWPbr'fHgEr8(.*8)`VFA+1+&Q(+loBW0XJbQM?jo]j+#?f9G&OWPngFMU`0-ca8t`Y_M=#'e-/5ML7(pOujXrD!i_=hH]Zc_qn\.[1gGs0mja.PjIs!ADVNeLpg=>In+L3_@6qp\b9n:']BPb54)0k*MbY:pCGSiU:3QVoKQ0\Wk2RLct.[c`u00c*@8)QIh!i+b7m\P/AI`r7[X;CJq^2E>(5VkU_!Uj(T&UOo#8W0VDZuZ)L$X=CR_b%Oa#Dm`111Z\+8jOOpQ@&S(k=UoK#^`h;l/9(u.UhAop*mif]!;3AU$'ES?+\H;6,nHMla1/m@$@ca-)N],At$)a\>/XK/,b"h&j'0ao-NK\2:@$%[FjE-t's1.SnVk>de!\EUEDA'T3&fEcf.#1SRd,b\P/X[i=;M5sl&as4--!?pBU0"&M,J1g]NZ%tN*jgu`"0stJ>f_IdaZ5>Z[>PrUj*j5P5-IG?GAbRqgUUO/cMr6O.IX*d"jWW:2T!&@.[^$62E;[R#+$%EkHYm.Y9["e%$KpC!=;@TJ9kVpHj8/iVY@*E2Z'(6%@U'<8%t\pU6nNS"Ejf5Fu?IU)3/WcHdCK/o&mJN^j-hkUE@DmK-,Dp5:2B/ne3e8>Ts)\o=e_\cVbi,f27^E^`bVn.p)J\;WEJ4DL1`D^Mj$V=VSHZRmD=Dk`)(cFFZ@L/E1nDr`o-LT6QMF'sE_=(A2qGLc*q`Sa+DZa,Xe$IcN-m#P%,0"EChMpf"@;,QSk::895BW(XUgt\_^4"1u:51R+Vp*Y_4i9Vr@Q-=:IbV0d)!Ah@!F=lBtn?@CbY]KE(>R4^R')&bOtU5h^S_s[[dWp;jj*Wi'RU#2kj_TgQje:jfNsB94%sEq&6n&]"%SF/#Tq(>'CjmNcqaiaoB$nY>=+tp.eNHLihdu74M8'^7l)TrY.8r=dg=lmT"7X&N_32[kTN`tl:-DT%LHVQp-M/g-;E58'_u52M&a0mK7B(@WsPYA_T^J%qc8K#+e,BM0Q:NoU2`^1">ha,s#H4G*+sdbU0(\t=PtugW%^$om3$gbc6[$3k9R:&F(7Yjj[d6f#I=(pU&hs#F]5_1#;9IE8b=Vm'(DC0!J-h=$,TZ2ZYiSSOe#)':%`OXse?NlTjT?4\778O?BBCK(K(8@(X=Vm.@8VEJNnD0*JL6>Lpj*;W)VZN'ORQ;GI:cq7_/KGm1FFFeH"0FYPdf!ZlcLY(3!AP+&BD)ff:8-UUd.O^)"PkMG[Iloh%=Ouk64%(L6ki;N_PqGLfpLgcgc&3M8XS^V`NJ2Z4Z/RG3D!mY"kLYVD>BY4[$d\^;!IRbt9i59mQ!@0s_TT_t+0=N]=K3luI+\(XfQ5e]5Y]q@ohAheJYVr>PF%OQCE86=gh!N`0L*^6_:QP?6u0r5%1hGWbC2_HPB4MX[cGE(9q;LO0fdX7\GmZ>>,\&:/tm\-t*OtW9\3/6\.A\6ZE8S%\So=R&Q]MAdBNSon:_JPqng:h-/j9AtJlrs2/=Ai!`(XA]<=>\>d?'auHY^s[UK,m!(>[:Pq]sS[Bca*GgBYh*1dE(%hE&QFc^dIdG#.H18:@0U,pbR1i0OHr%ZD%"dUD1"DuY4>c0PkmD1%2p#>4jE,*9"aVX9!`oVXR;d-Y3"Hq'?Sn=O;D/S!.>c4I`[@q^TH0/=d^]h("acNGHGDT9WS#ud0uPjK+i_$C(k.jXdJ36.nq.kcQm]seV);aZbO\Ir%1_ADK;E@NjCXla+i4-#d1O[jqH*^qL\^[c.1O'0C_rHV&m^]$\[[eFQ1TO;o>>(Oc.