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Accident or Injury Report

Accidental Injury Claim Form Aflac In California

Category:

Employment - Health and Safety

State:

Multi-State

Control #:

US-0022BG

Format:

Instant download

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Description

All accidents are considered as incidents; however an accident report form focuses more on the injury. An accident report is an important tool used to document the accident and assist in investigating the cause. It also assists to develop procedures that may be put in place to prevent it from happening again.

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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.

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).

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: ▪

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.

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.

You can mail your claim form to Post Office Box 84075, Columbus, Georgia 31993. You may also fax your claim form to our claims department at 866.849. 2970 or scan and email your claim form to groupclaimfiling@aflac.

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

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File your claim via fax or mail. Consider filing online for faster claims payment!Simply select "File Online" below and follow the instructions. Please provide a date and complete description of your accident. To file your claim via fax or mail, simply download the appropriate forms below, and send to us with all necessary supporting documentation. File your claim with Aflac SmartClaim®: 1. Access Aflac SmartClaim from MyAflac or the MyAflac Mobile app. 2. Have your doctor complete Section B: Physician's Statement. Ambulance - HCFA 1500, ambulance bill or police report. PATIENT'S CLAIM FORM - Please fully complete the top half.

Accidental Injury Claim Form Aflac In California

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