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AFLAC DULUTH DISTRICT OFFICE

CLAIM FORM

*Denotes Required Fields

*Today's Date

POLICYHOLDER INFORMATION

*Name:
   
*Street Address:
P.O. Box
*City:
*State:
*Zip:
*Phone Number:
Fax Number
*Employer:
*Email:

PATIENT INFORMATION
*Nature of Claim:
*Patient's Name:
*Date of Birth:
Date of Service:
Treated By:
Disability Dates:
Hospital/Clinic:
Hospitalization:
Address:
Surgery:
Phone/Fax:
Appliance:
Phone/Fax:

INSURANCE INFORMATION
*Policy #:
*Policy Type:
Effective Date:
Policy #:
Policy Type:
Effective Date:
Policy #:
Policy Type:
Effective Date:
Policy #:
Policy Type:
Effective Date:
Policy #:
Policy Type:
Effective Date:
Policy #:
Policy Type:
Effective Date:

 

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American Family Life Assurance
Company of Columbus (AFLAC)
 
This site is independently owned and operated by Pam DeShaw-Brackett, an independent insurance agent licensed in Minnesota and Wisconsin. This agent runs the Duluth District Office representing independent agents of AFLAC. This site is a communication tool between the Duluth District Office and the policyholders of AFLAC in the Twin Ports area of Minnesota and Wisconsin only and is in no way associated with, maintained by, or representing www.aflac.com. This site is 100% independent of AFLAC. Please contact us if you have questions concerning this affiliation.