Policyholder Information: This * denotes a required field.

*Policy Number:

/ / - -

-

Patient Information:

*Last Name Suffix *First Name MI

*Date of Birth (mm/dd/yy) Telephone Number where we can reach you

*Home Address

*City *State *Zip Code

• Date of the injury: / /

• Describe how the injury occurred:

• Was this injury caused by an incident that occurred while performing the duties of his/her employment? No Yes

• Was injury a result of participating in an organized sporting activity? No Yes

Type of Event AND Sporting Organization

• Was this a motor vehicle accident in which the patient was the driver? No Yes (If yes, please submit a copy of the

Police Report.)

• Was death a result of this injury? No Yes (If yes, please submit the certified death certificate and the Life-

Beneficiary’s Statement.)

• Was the patient confined to the hospital as a result of this injury? No Yes (If yes, please submit the UB04

aflac.com/smartclaim.

To prevent delays, please provide documentation from your healthcare provider to support this claim. If you have

additional bills or medical documentation that relates to this diagnosis other than the documentation defined, please

submit them for review of additional benefits.

➢ Service related items can be obtained directly from the patient’s healthcare provider(s) by requesting a UB04

hospital bill or HCFA 1500 non-hospital bill.

➢ Failure to complete all sections may result in a delay in processing this claim.

➢ Disclaimer: Some of the services listed may not be covered by your policy.

• Was the patient transported by an ambulance as a result of this injury? No Yes (If yes, please submit the

ambulance bill.)

• Was an aid in locomotion (mobility) prescribed as a result of this injury? (I.e. crutches, wheelchairs, leg braces, back

braces, walkers, cervical collars, etc.) No Yes (If yes, please submit documentation from the prescribing provider,

UB04 or HCFA 1500.)

• If any of the following were the result of your injury, please provide medical records, physician’s office notes, or any bills

received for these conditions that describe the diagnosis or type of treatment received:

• Coma • Laceration

• Paralysis • Dislocation

• Burn • Concussion (major diagnostic exam reports are acceptable)

Policyholder Information:

*Policy Number:

Patient Information:

*Last Name Suffix *First Name MI

*Date of Birth (mm/dd/yy)

*Last Name *First Name *Date of Birth (mm/dd/yy)

• Transportation/Lodging Information: Please complete if you are filing a claim for transportation or lodging and please

submit the hotel receipts and mileage information. For additional information, please refer to your policy language.

* Some policies provide benefits for therapy including physical, speech, and occupational therapy. Not all types are available

on all policies. Please submit information indicating date of treatment, treatment type, and who provided it to determine

benefit.

Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance or statement of claim containing any materially false information or conceals for

the purpose of misleading, information concerning any fact material thereto, commits a fraudulent

insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand

dollars and the stated value of the claim for each such violation.