Filing Claims | Aflac Group

Aflac is here to help. 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.

Claims are subject to policy terms and conditions.

File a Wellness Benefit Claim Online

Simply select “File Online” below and follow the instructions.

File a Wellness Benefit via Fax or Mail

Please fully complete the claim form for the Wellness Benefit.

Please date and sign all required forms where indicated.

Forms:

Wellness Claim Form

File an Accident Claim Online

Simply select “File Online” below and follow the instructions.

File an Accident Claim via Fax or Mail

Please provide a date and complete description of your accident. You can provide this information in the designated space on the claim form.

If the accident resulted from the use of a motor vehicle(s), a copy of the police or accident report is required. If your injury occurred on the job, a first report of injury filed with your employer must be attached to the completed claim form.

If you were first treated in an emergency room, a copy of the hospital discharge papers is required to verify the first date of treatment, diagnosis, and procedure.

Please include all dates of treatment and charges incurred due to the accident.

Please date and sign all required forms where indicated.

Forms:

Group Accident Claim Form

Group BenExtend Claims

A BenExtend claim requires supporting documentation for review of benefits such as an itemized bill if there was a hospital stay, itemized bill from physician’s office, surgical report if surgery took place, Xray/Diagnostic Test reports with dates and charges if applicable, accident report if applicable, and a signed and dated Authorization for Disclosure of Health Information (HIPAA form).

Please date and sign all required forms where indicated.

Forms:

Group BenExtendSM Claims

File a Cancer Claim via Fax or Mail

Please submit the pathology report used in the diagnosis of a malignant cancer, the claimant’s birth certificate, and any itemized medical bills with the diagnosis and procedure codes, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). 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 Pre-Existing Investigation Statement.

Please date and sign all required forms where indicated.

Forms:

Group Cancer Claims

File a Critical Illness Claim Online

*Before filing a critical illness claim online, please ask your physician to complete and return the Physician’s Statement Form*

If you have already had your physician complete and return this form, simply select “File Online” below and follow the instructions.

Physician’s Statement Form

File a Critical Illness Claim via Fax or Mail

For critical illness claims, we need information from you and your attending physician. Please provide all information requested on the Insured’s Statement portion of the claim form. The Attending Physician’s statement portion of the critical illness claim form is to be completed by the physician who first diagnosed your condition. 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). 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 Pre-Existing Investigation Statement.

Please date and sign all required forms where indicated.

Forms:

Group Critical Illness Claims

File a Dental Claim via Fax or Mail

Please complete the Patient section, Boxes 8–18, as well as the Policyholder/Employee section (excluding Boxes 31–38 and 40.) Your dentist should complete the Billing Dentist section, Boxes 42–66 (excluding Box 53).

Please date and sign all required forms where indicated.

Forms:

Group Dental Claims

File a disability via Fax or Mail

For disability claims, we will need information from you, from your employer, and from your attending physician. Please provide all the information requested in Part A of the initial claim form. Your employer is responsible for providing the information in Part B, and your attending physician is responsible for providing the information in Part C.

In addition, please read and then sign the Authorization for Disclosure of Health Information (HIPAA form) included in Part A, as well as the separate Authorization for Disclosure of Health Information (HIPAA form).

Please date and sign all required forms where indicated.

Forms:

Disability Claim Form

Continuing Disability Claim Form

If this is a Disability Product with your policy number beginning with AFL, please use the form below.

Short Term Disability/Long Term Disability Claim Form

File a Hospital Claim Online

Simply select “File Online” below and follow the instructions.

File a Hospital via Fax or Mail

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). 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 Pre-Existing Investigation Statement.

Please date and sign all required forms where indicated.

Forms:

Hospital Indemnity Claim Form

Group Life Insurance or Accidental-Death and Dismemberment Insurance Rider Claims

Please provide a certified copy of the deceased person’s birth certificate and death certificate. If the cause of death is an injury or accident, include a copy of any related police report and/or newspaper articles.

Please date and sign all required forms where indicated.

Forms:

If your certificate number issued to you is in a numerical value, Example: 1234567891, please only use the two forms below.

Accelerated Death Benefit Claim Form

Beneficiary’s Statement for Death Claim Form

If this is an Employer Sponsored Term Life Product with your policy number beginning with AFL, please use the forms below.

Death Benefit Proceeds Claim Form

Life Waiver of Premium Claim Form