Aflac Interest Form PDF Details

Aflac is a company that provides supplemental insurance plans for individuals and groups. If you are interested in obtaining a policy through Aflac, or if you would like to learn more about the company, you can fill out an interest form on their website. The form allows you to provide information about yourself and your needs, and it will help Aflac determine what policies might be right for you. Filling out the form is easy and takes only a few minutes, so it's a great way to get started on finding the right coverage.

Form NameAflac Interest Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesaflac interest printable, aflac application forms, aflac interest sheet, aflac blank form

Form Preview Example

Aflac Interest Sheet

1 Personal Info **Please complete all fields**










Job Title:______________________________________
















Dependent Children: Yes or No

(Includes all children up to age 26)



Address: _____________
























2 Available Plans **Want more information? Just check the plan you would like to hear more about**


Employee & Spouse

1 Parent Family

Family Plan____




Specified Health Event (HEART/STOKE)




Short Term Disability

Disability quoted individually based on salary and other criteria.

3 How Aflac Works

AFLAC pays CASH benefits directly to you, not the doctor or hospital.

AFLAC benefits can be used to pay co-pays, deductibles & other out of pocket medical expenses.

AFLAC benefits are designed to pay every day living expenses like Rent or mortgage, groceries, utilities, car payments and more.

AFLAC plans are GUARANTEED renewable, meaning we will never cancel on you. AFLAC policies are PORTABLE. Even if you change jobs, you can take it with you. AFLAC has NEVER had a rate increase, so you know the cost in the future.

AFLAC pays 92% of our claims in 4 days, so you get the money when you need it most. AFLAC has been named Ethisphere’s ost ETHICAL I sura ce Co pa y 5 years i a row! AFLAC plans provide a safety net of cash for about an hour’s wage per week

AFLAC policies can be extended to cover the whole FAMILY

Your Agent: Juanita Burks, CA License # O640977

Phone: 310-590-7820


4 Policy Infromation

Accident Indemnity Advantage

Covers you & your family 24/7

At work, Sports, School, Home and Commuting

Pays $1,000 initial Hospitalization benefit/$2000 Intensive Care

Hospital Confinement benefit of $250 per day

Wellness payout of $60 every 12 months for routine check ups

Dental Insurance

No co-pays, no deductibles, NO NETWORKS

Annual benefits amounts range from $1,200 to $1,800 per person depending on plan

Benefits for Orthodontics and Cosmetic dentistry can be added.

Short Term Disability

***Guaranteed Issued ***for new policies

Benefits from $500 to $5,000 per month

Pays in 4 days compared to 30 days the state requires to process.

Benefits are own occupational payouts

Life Insurance

Plans include 10, 20, 30 year term & Whole life

Benefit amounts as high as $200,000

**If you have Major Medical you can also access these programs**

Personal Cancer Care

$6,000 initial diagnosis benefit, builds by $500 per year

$300 per day for hospitalization

$500 per week for experimental treatment, No Major Medical plan covers this

Pays you $100 per covered person in wellness every year

Hospital Advantage

***Guaranteed Issued ***for new policies

Covers hospitalizations for Accidents, Sickness and pregnancies

Pays $1000 first day of hospital confinement

Pays daily hospitalization benefit

Pays wellness benefit of $150 every year, per person covered for Medical Diagnostic & Imaging

Specified Health Event

Covers heart attack, stroke, by-pass, coma & paralysis

$5,000 initial diagnosis benefit, builds by $500 per year

$300 per day for hospitalization

$ Pays wellness benefit of $150 every year for Mammograms