Aflac Form S13270 Ca PDF Details

If you are a Massachusetts resident and have been injured at work, you may be wondering what your workers' compensation options are. The first thing you should do is fill out an Aflac Form S13270 Ca, which is a claim for benefits form. This form will help you start the process of filing a claim for workers' comp benefits. There are also several other steps that you will need to take in order to ensure that your claim is processed properly. In this blog post, we will discuss the steps that you need to take to file a workers' compensation claim in Massachusetts. We will also provide some tips on how to make the process as smooth as possible. So, if you have been injured at work, keep reading for more information

QuestionAnswer
Form NameAflac Form S13270 Ca
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesaflac continuing disability form to print, aflac continuing disability form employer's statement, aflac short term disability claim form, aflac short term disability claim form 2021

Form Preview Example

CONTINUING DISABILITY CLAIM FORM

Failure to complete this form in its entirety may result in a delay in processing this claim.

FILING CLAIM FOR (check all that apply):

Disability due to an Accident

Disability due to a Sickness

Disability due to Pregnancy / Complications

Disability due to Cancer

Cancer

Policy Number

Accident

Policy Number

Short-Term Disability/

Sickness Rider

Policy Number

Hospital Indemnity

Policy Number

Hospital Intensive Care

Policy Number

Life

Policy Number

INSTRUCTIONS:

Be sure to include your policy number(s) on all documents.

Complete and sign Section A: Policyholder/Patient Information.

Your employer should complete and sign Section B: Employer’s Statement.

If you are a contract, 1099, or self-employed worker, please submit your prior-year tax return (Schedule C) and current-year estimated tax payments (1040ES).

Your physician should complete and sign Section C: Physician’s Statement.

If hospitalized and/or confined to an intensive care unit/step-down unit, please send a copy of your hospital bill showing charges and the number of days you were confined. These items can be obtained directly from your healthcare provider(s) by requesting a UB04 (hospital bill) or HCFA 1500 (nonhospital bill).

Please include a certified copy of the death certificate if the patient is deceased.

This claim form should be completed on or after the initial date of your disability, hospitalization, and/or surgery. Forms completed prior to the initial date may result in a delay in processing this claim.

SECTION A: POLICYHOLDER INFORMATION (please print)

First Name

Initial Last Name

Mailing Address

City

Check box if this is a new permanent address:

Social Security Number

PATIENT INFORMATION (please print)

First Name

 

Initial

Relationship:

 

Sex:

Primary Policyholder

Spouse

Male

State ZIP

Phone Number

Last Name

Female

Patient Date of Birth: _____/_____/_____

Have you returned to work at any job?

Yes

No

Date of Incident: _____/_____/_____

Describe where and how the incident occurred:

 

 

 

For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

_________________________

_________________________

____________

CLAIMANT SIGNATURE

FAMILY RELATIONSHIP, IF NOT POLICYHOLDER

DATE

American Family Life Assurance Company of Columbus (Aflac)

Attn: Claims Department • W orldwide Headquarters • 1932 W ynnton Road • Columbus, GA 31999

For information or help filing your claim, please call toll-free or visit our W eb site at aflac.com.

Toll-free fax number: 1.877.44.AFLAC (1.877.442.3522)

S13270 -CA

Page 1 of 3

07/11

CONTINUING DISABILITY CLAIM FORM - EMPLOYER’S STATEMENT

Failure to complete this form in its entirety may result in a delay in processing this claim.

For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Policy Number:

Policyholder’s Name:

 

 

 

Patient Name:

 

 

 

Date of Birth:

 

 

 

 

SECTION B: EMPLOYER’S STATEMENT

 

 

 

 

 

 

 

EMPLOYER’S NAME

 

PHONE NUMBER

FAX NUMBER

 

 

 

 

 

( )

 

 

( )

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS

 

CITY

STATE

ZIP

 

 

 

 

 

 

 

 

 

1.

First date of disability: _____ /_____ /_____

 

 

 

2.

Has the policyholder returned to work?

Yes

No

 

 

 

If yes, is the policyholder working

Full-Time

Part-Time

 

 

 

If the policyholder is working part-time, date he or she began part-time: _____ /_____ /_____

 

Date returned (or expected to return) to full-time duty: _____ /_____ /_____

 

 

3.

Is the policyholder currently earning at least 80% of his or her predisability salary?

Yes

No

4. Is the person still employed?

Yes

No If no, last date of employment:

 

/

 

/

Please note:

The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee’s Form W-2.

EMPLOYER’S SIGNATURE

 

TITLE

DATE

 

 

 

 

EMPLOYER’S PRINTED NAME

 

DIRECT PHONE NUMBER

 

American Family Life Assurance Company of Columbus (Aflac)

Attn: Claims Department • W orldwide Headquarters • 1932 W ynnton Road • Columbus, GA 31999

For information or help filing your claim, please call toll-free or visit our W eb site at aflac.com.

Toll-free fax number: 1.877.44.AFLAC (1.877.442.3522)

S13270 -CA

Page 2 of 3

07/11

CONTINUING DISABILITY CLAIM FORM - PHYSICIAN’S STATEMENT

Failure to complete this form in its entirety may result in a delay in processing this claim.

For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Policy Number:

Policyholder Name:

Patient Name:

 

 

Date of Birth:

SECTION C: PHYSICIAN’S STATEMENT (Must be completed by physician or physician’s staff. If completed by a member of the physician’s staff, then physician must sign the form)

PHYSICIAN’S NAME

PHONE NUMBER

FAX NUMBER

 

 

(

)

(

)

 

 

 

 

 

 

MAILING ADDRESS

CITY

 

STATE

ZIP

 

 

 

 

 

 

1.

First date of disability:

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date patient was last treated:

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

2.

If this is a pregnancy claim, date of delivery:

 

 

/

 

/

 

 

 

If not delivered, expected delivery date:

 

 

/

 

 

 

/

 

 

 

 

 

Please advise of any complications.

 

 

 

 

 

 

 

 

 

 

 

 

Vaginal

Cesarean

3.Diagnosis Description and ICD code:

4.Was patient hospitalized as a result of this diagnosis? Yes No

 

Admission:

 

/

 

/

 

 

Discharge:

 

 

/

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

State:

 

 

5.

Have you released the patient to return to work?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

If patient has not been released to return to work, please provide the next appointment date:

/

 

/

 

 

 

 

Please also provide the date of expected release:

 

 

/

 

 

/

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

If the patient has been released, please provide the date released:

/

 

 

/

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient released to work:

Full-time

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If part-time, please provide the date the patient is expected to return to full duty:

 

 

/

 

 

 

 

/

 

 

 

.

 

8.

If patient is not employed ful-time, which Activities of Daily Living (ADLs) is the patient unable to perform?

 

 

 

Check and initial all that apply:

Continence

Transferring

 

Dressing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bathing

Toileting

 

 

 

 

 

Eating

 

 

 

 

 

 

 

 

 

 

 

 

9.Does this patient require direct personal assistance to perform these ADLs each and every time? If yes, how many days will the patient require direct personal assistance?

Yes

No

PHYSICIAN’S SIGNATURE

DATE

TAX ID NUMBER

American Family Life Assurance Company of Columbus (Aflac)

Attn: Claims Department • W orldwide Headquarters • 1932 W ynnton Road • Columbus, GA 31999

For information or help filing your claim, please call toll-free or visit our W eb site at aflac.com.

Toll-free fax number: 1.877.44.AFLAC (1.877.442.3522)

S13270 -CA

Page 3 of 3

07/11

How to Edit Aflac Form S13270 Ca Online for Free

aflac short term disability claim form 2021 can be filled out without difficulty. Simply use FormsPal PDF editor to complete the task fast. To keep our editor on the leading edge of convenience, we work to adopt user-driven capabilities and improvements regularly. We are routinely pleased to receive suggestions - help us with reshaping how we work with PDF documents. This is what you would need to do to get going:

Step 1: Just hit the "Get Form Button" in the top section of this page to open our pdf editor. There you'll find everything that is required to fill out your file.

Step 2: This tool enables you to customize PDF forms in various ways. Enhance it with customized text, correct what is originally in the document, and place in a signature - all at your fingertips!

With regards to the blank fields of this precise document, here is what you should know:

1. Complete your aflac short term disability claim form 2021 with a selection of major blanks. Gather all of the information you need and make certain there is nothing left out!

aflac continuing disability form conclusion process detailed (portion 1)

2. After this segment is done, you're ready insert the essential particulars in If yes please complete the, Yes, For all claims please complete all, Was the patient confined to the, Yes If yes please submit the, hospital bill UB or HCFA Hospital, State, Any person who knowingly and with, POLICYHOLDERPATIENT SIGNATURE, FAMILY RELATIONSHIP IF NOT, DATE, American Family Life Assurance, ATTN Claims Department Wynnton, For information or to check claim, and Claims may be faxed to AFLAC in order to go further.

aflac continuing disability form completion process clarified (part 2)

3. The third part is generally easy - complete all of the blanks in CONTINUING DISABILITY CLAIM FORM , Policy Number, Policyholder Information This , Last Name, Suffix, First Name, Date of Birth mmddyy, Employees Name Last Name Suffix, Employers NameAccount , Employers Address, Employer Phone Number, State, Zip Code, City, and First date of disability to finish this process.

aflac continuing disability form writing process described (stage 3)

Be very careful when filling out Last Name and State, since this is where many people make errors.

4. All set to fill in this next form section! In this case you will get all of these If no expected return to work date, If yes date returned to work, If the employee has returned to, FullTime, PartTime, Light Duty, If employee is working parttime or, If working parttimelight duty date, If working parttime date expected, If parttimelight duty iswas the, Yes, Is the person still employed, Yes If no last date of employment, Please note, and The employer is required to report blanks to fill out.

The employer is required to report, FullTime, and Is the person still employed in aflac continuing disability form

5. To conclude your form, this particular segment involves several extra blanks. Completing EMPLOYERS SIGNATURE, EMPLOYERS PRINTED NAME, TITLE, DIRECT PHONE NUMBER, DATE, American Family Life Assurance, ATTN Claims Department Wynnton, For information or to check claim, Claims may be faxed to AFLAC , and Page of should finalize the process and you will be done in a short time!

aflac continuing disability form completion process described (step 5)

Step 3: After you've reviewed the information in the file's blank fields, simply click "Done" to finalize your document generation. Right after starting a7-day free trial account here, it will be possible to download aflac short term disability claim form 2021 or send it via email directly. The file will also be at your disposal in your personal account page with your each and every edit. FormsPal offers risk-free document completion with no personal information record-keeping or sharing. Feel safe knowing that your information is in good hands here!