Aflac Form S13270 Ca – Fill Out and Use This PDF

The Aflac S13270 Ca form is a detailed document designed to process continuing disability claims for individuals affected by accidents, sickness, pregnancy complications, or cancer. It necessitates comprehensive information from the policyholder, their employer, and their physician to ensure a smooth claim process. Failure to accurately complete this form can lead to delays, underscoring the importance of careful form submission.

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Aflac Form S13270 Ca PDF Details

Navigating through the complexity of disability claims can be a daunting task for many, and the Aflac S13270 CA form serves as a pivotal instrument for policyholders in California facing such challenges. This comprehensive form is designed for individuals filing claims relating to continuing disability due to various causes such as accidents, sickness, pregnancy complications, or cancer. To ensure expedited processing, the form emphasizes the importance of thorough completion, covering a multitude of sections including policyholder and patient information, employer's statement, and physician's statement. Additionally, specific conditions are laid out for contract workers, who are required to submit detailed financial documents. Bearing in mind the legal consequences of fraudulent claims, the document reinforces the seriousness of accuracy in reporting. Obtaining accurate documentation from healthcare providers, including hospital and non-hospital bills, is critical for claim substantiation. Furthermore, it caters to scenarios of deceased patients by requesting a certified copy of the death certificate. The practicalities of completing the form post-disability onset, the necessity of including policy numbers, and the mandatory adherence to California's legal requirements encapsulate the form's significance in providing a structured pathway for individuals seeking disability benefits through Aflac.

Question	Answer
Form Name	Aflac Form S13270 Ca
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	aflac 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

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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

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.

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.

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

First date of disability:

Date patient was last treated:

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:

Have you released the patient to return to work?

Yes

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

Please also provide the date of expected release:

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:

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

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

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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)

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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)

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Aflac Form S13270 Ca – Fill Out and Use This PDF

Aflac Form S13270 Ca PDF Details

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