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Accident/Disability Claims
To file an accident claim or a disability claim, please complete the appropriate claim form and follow the guidelines below:
Accident Claims (Form S-00198)
- Include an authorization signed and dated by the patient with every claim.
- Have the patient complete and sign Section A: Patient Information.
- Have your physician complete and sign Section B: Physician's Information.
- For motor vehicle accidents, include:
- A copy of the police report
- A copy of the blood alcohol report or drug screening if the patient was tested for alcohol or drugs
- A certified copy of the death certificate if the patient is deceased
First Claim for Disability Due to Accident (Form S-00198)
- Have the patient complete and sign Section A: Patient Information.
- Have your physician complete and sign Sections B and C: Physician's information and Physician's Disability Statement.
- Have the employer complete and sign Section D: Employer's Information. Please ensure that the employer complete the pre-tax or after-tax question.
- If you are self-employed, send a copy of your current business license and most recent quarterly tax records.
- Be sure the claim form includes:
- Where and when the accident took place (on or off the job)
- Dates of disability
- Name and phone number of the physician
Additional information may be required.
Second and Subsequent Claims for Disability (Form S-13270.1)
Have the patient complete and sign Section A: Patient Information.
Have the physician complete and sign Section B: Physician's Information.
Have your employer complete and sign Section C: Employer's Information.
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Aflac New York Toll-Free:
1-800-366-3436
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