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¢ DUCK Accident/Hospital Indemnity Wellness Benefit Claim Form If you are interested in filing your claim online, register using aflac.com/smartclaim. Benefits of filing your claim online include faster claim processing time and receiving claim communications by email. Please read all instructions and complete the form, failure to do so could delay the processing of your claim. Please check your policy for specific details on this benefit. • Do not include receipts, statements or other claim documentation with this form. • Do not write on form except as instructed. • Sign, date and fax or mail the completed form to the Aflac fax number/address shown below. • Use black or blue ink only and print legibly when completing this form in its entirety. • Mark only wellness exam boxes for test(s) and/or treatment(s) received. • Failure to complete all sections may result in a delay in processing this claim. • Some types of tests and/or treatment listed may not be covered by your policy. Please keep a copy of this completed form for your records. Please print a separate form for each additional family member or call 1-800-99-AFLAC (1-[PHONE REDACTED]) to request additional forms. Claims for all other benefits covered under this policy must be filed separately using the claim forms available at aflac.com or by calling 1-800-99-AFLAC (1-[PHONE REDACTED]). CW061999 Page 1 of 2 American Family Life Assurance Company of Columbus (Aflac) ATTN: Claims Department • 1932 Road • Columbus, GA 31999 For information or to check claim status, visit aflac.com or call 1-800-99-AFLAC (1-[PHONE REDACTED]) Claims may be faxed to 1-877-44-AFLAC (1-[PHONE REDACTED]) 02/14 ---PAGE BREAK--- Policyholder Information: Policy Number: Patient Information: Home Address City State Zip Code Last Name First Name Date of Birth (mm/dd/yy) POLICYHOLDER/PATIENT SIGNATURE FAMILY RELATIONSHIP, IF NOT POLICYHOLDER DATE Physician's Street Address Physician's City State: Zip: Physician's Name Physician's Phone Number: Check box if this is permanent address change. Annual Physical Ultrasound PSA (blood test for prostate cancer) Pap Smear Blood Screening Immunizations Eye Exam Dental Exam I I I I I I I I I I I I 111111111111111 ITJ 111111111111 □ / - - / I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I ITJ I I I I I I □ I I I I I I I I I I I I I I I I I 11 I I I I I I I I I I 11 I I I I I I I I □ □ □ □ □ I I I I I I I I I I I I I I I I I I I I I I I I I I I □ □ □ □ □ □ □ □ □ □ I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I ITJI 11111 Accident/Hospital Indemnity Wellness Benefit Claim Form Sex: Male Female / / Relationship: Primary Policyholder Spouse Dependent Child Treatment and Physician Information M M D D Y Y Y Y M M D D Y Y Y Y M M D D Y Y Y Y Pap Smear Treatment Mammogram Date: Date: Date: Flexible Sigmoidoscopy Mammogram - - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals 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. CW061999 Page 2 of 2 American Family Life Assurance Company of Columbus (Aflac) ATTN: Claims Department • 1932 Road • Columbus, GA 31999 For information or to check claim status, visit aflac.com or call 1-800-99-AFLAC (1-[PHONE REDACTED]) Claims may be faxed to 1-877-44-AFLAC (1-[PHONE REDACTED]) 02/14 SIGN