Fillable Form Ny-S-00198 - Accidental Injury Claim Form

ACCIDENTAL INJURY CLAIM FORM

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

Complete Policyholder/Patient Information and sign your claim form.

Have the treating physician complete Section B: Physician's Statement and sign the claim form or

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 HCFA1500

(non-hospital bill).

If you are filing for disability, please complete the Initial Disability Claim Form (NY-S00224) as well. Forms are available on our web site at

Policyholder Information

Policy Number

(Please print.)

First Name

Last Name

Initial

Mailing Address

City

State

ZIP

Check box if this is a

new permanent address:

Social Security Number

Phone Number

Patient Information

(Please print.)

First Name

Initial

Last Name

Relationship:

Sex:

Primary Policyholder

Spouse

Male

Female

Patient Birth Date:

Dependent Child

Check here if dependant child is a full-time student (if over the age 19, please provide school name and

contact information).

Please answer the following questions. The claim cannot be processed until all necessary information is provided:

: ___________

Date of accident

Describe how the accident happened: ________________________________________________

________________________________________________________________________________

______________________

Location of the accident?

On the job

Off the job

Other (please describe):

Was the patient the driver in a motor vehicle accident?

Yes (Attach the police report)

If the patient sought treatment (

50 /

100) or more miles from his/her residence and required lodging for patient's relative while

the patient was confined in hospital then submit the hotel receipt(s). Please check your policy to verify the mileage your policy covers.

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.

_____________________

___________________________

___________

CLAIMANT SIGNATURE

FAMILY RELATIONSHIP, IF NOT POLICYHOLDER

DATE

American Family Life Assurance Company of New York (Aflac New York)

Attention: Claims Department • 1932 Wynnton Road • Columbus, GA 31999-7255

For information or help filing your claim, please call toll-free 1-800-366-3436 or visit our Web site at

Toll-free fax number 1-877-844-0201

07/08

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NY--S-00198

Form Ny-S-00198 - Accidental Injury Claim Form - 2008

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