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Get New Claim Form Pdfs For Web - Cw06199

Nceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and subjects such person to criminal and civil penalties. The Provider listed above is authorized to validate the information I have provided. POLICYHOLDER/PATIENT SIGNATURE CW061999 FAMILY RELATIONSHIP, IF NOT POLICYHOLDER DATE Page 2 of 2 American Family Life Assurance Company of Columbus (Aflac) ATTN: Claims Department 1932 Wynnton Road Colu.

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