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Download Aflac Short Term Disability Claim Form, also known as Aflac Initial Disability Claim Form. This form is used to file a claim for short term disability. If disability, is later, determined to be for a longer term, there will be follow up forms required at that time. Be certain to include all supporting documentation in your claim. * is a required field.

How To Write

Step 1 – Read the paragraphs at the top of the form and provide all information accurately as follows:

  • Policy Number
  • Last Name
  • Suffix (ie: Dr., Jr. I, II, III etc.)
  • First Name
  • Date of Birth (mm/dd/yyyy)
  • Telephone number where you can be reached
  • Home Address
  • City
  • State
  • Zip + 4
  • Check the box to the left if this is a permanent address change

Step 2 – Patient Information

  • Last Name
  • First Name
  • Date of Birth (mm/dd/yyyy)
  • Sex (check one)
  • Relationship (check applicable box)

Step 3 – Initial Disability Check list (answer all inquiries below)

  • Is this disability due to a sickness (check yes or no)
  • Is this disability due to an injury (check yes or no)
  • If yes, please complete the following questions related to the injury:
  • Date of Injury (mm/dd/yyyy)
  • Describe how the injury occurred
  • Was this disability caused by an incident that occurred while performing duties of the patient’s employment? (check yes or no)
  • Was this a motor vehicle accident in which the patient was the driver? (check yes or no- (If yes you must submit a police report)

Step 4 – For all claims, complete all remaining sections

  • Was the patient confined to the hospital as a result of this condition? (check yes or no)  (If yes, you must submit the itemized hospital bill, UBO 4 or HCFA 1500)
  • Hospital Name
  • City
  • State
  • Read the paragraph, if agreed:
  • Policyholder/Patient Signature
  • Family Relationship if not policyholder
  • Date mm/dd/yyyy

Step 5 – Initial Disability Claim Form – EMPLOYER’S STATEMENT

  • This area of the form is reserved only to be completed by the employer. Do NOT fill in any of this information, it is required that the employer complete, sign and date this portion of the form.

Step 6 – Initial Disability Claim Form – PHYSICIAN’S STATEMENT

  • This portion of this form is for the Physician only. Do NOT complete any part of the Physician’s State portion of this form. All information must be provided by the physician. As well, it must be signed and dated by the physician. Tax ID number must also be provided by the physician.

 

 

 

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