[Form] File a Hospital Indemnity Claim

Policyholder Information: This * denotes a required field. *Policy Number: / / / / - - - - - Patient Information: / / / / HOSPITAL INDEMNITY CLAIM FORM Thank you for trusting Aflac with your Hospital Indemnity needs. ­ If you are interested in filing your claim online or uploading documentation on an existing claim, register using 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. DUCK *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 *Last Name *First Name *Date of Birth (mm/dd/yy) *Sex: Male Female *Relationship: Primary Policyholder Spouse Dependent Child American Family Life Assurance Company of Columbus (Aflac) ATTN: Claims Department • 1932 Wynnton Road • Columbus, GA 31999 For information or to check claim status, visit aflac.com or call 1-800-99-AFLAC (1-800-992-3522) Claims may be faxed to 1-877-44-AFLAC (1-877-442-3522) S2029 Page 1 of 2 02/14 Check box if this is a permanent address change. Hospital Indemnity Checklist *If filing for a claim within the first two years of the policy, medical records may be requested for evidence of insurability. Is treatment due to an injury? No Yes If yes, please complete the following questions related to the injury: • Date of the injury: / / • Describe how the injury occurred: • Was this disability caused by an incident that occurred while performing the duties of the patient’s employment? No Yes • 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.) Is treatment due to a sickness? No Yes If yes, please complete the following questions related to the sickness: • Symptoms first occurred on: / / • First date of treatment for this condition: / / • If diagnosed with cancer, date of initial diagnosis: / / • Was the patient treated by any other physicians for this sickness or a related condition? No Yes If yes, physician’s name(s): Phone Number(s): Address:

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. Policyholder Information: *Policy Number: Patient Information: / / / / Pregnancy claims: • Date of delivery: / / Vaginal Cesarean • If not delivered, expected delivery date: / / • Please advise of any complications: For all claims, please complete all remaining sections. • Please provide the name, address and phone number of the patient’s primary treating physician. Name: Phone Number: Address: • Was the patient confined to the hospital as a result of this condition? No Yes (If yes, please submit the itemized hospital bill, UB04, or HCFA 1500) Hospital Name: City: State: • Was the patient confined to the intensive care unit as a result of this condition? No Yes (If yes, please submit the itemized bill, UB04, or HCFA 1500.) • Was the patient confined to a rehabilitation unit as a result of this condition? No Yes (If yes, please submit the itemized bill, UB04, or HCFA 1500.) • Was patient treated in an emergency room as a result of this condition? No Yes (If yes, please submit the emergency room report, UB04, or HCFA 1500.) Hospital name: Date of treatment: / / • Was the patient transported by an ambulance as a result of this condition? No Yes (If yes, please submit the ambulance bill) • Was surgery performed as a result of this condition? No Yes (If yes, please submit a copy of the operative report, UB04, or HCFA 1500.) • Were medical imaging services (i.e. CT Scan, MRI, EEG, etc.) provided as a result of this condition? No Yes (If yes, please submit a copy of the exam report and/or billing, UB04, or HCFA 1500.) *Last Name Suffix *First Name MI *Date of Birth (mm/dd/yy) *Last Name *First Name *Date of Birth (mm/dd/yy) 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 subjects such person to criminal and civil penalties. American Family Life Assurance Company of Columbus (Aflac) ATTN: Claims Department • 1932 Wynnton Road • Columbus, GA 31999 For information or to check claim status, visit aflac.com or call 1-800-99-AFLAC (1-800-992-3522) Claims may be faxed to 1-877-44-AFLAC (1-877-442-3522) S2029 Page 2 of 2 02/14 POLICYHOLDER/PATIENT SIGNATURE FAMILY RELATIONSHIP, IF NOT POLICYHOLDER DATE