Hospital Indemnity Claim Form: Policy Number
Hospital Indemnity Claim Form: Policy Number
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.
*Policy Number:
Policyholder Information: This * denotes a required field.
*Last Name Suffix *First Name MI
/ / - -
*Home Address
/ /
*Policy Number:
Policyholder Information:
*Last Name Suffix *First Name MI
/ /
Patient Information:
*Last Name *First Name *Date of Birth (mm/dd/yy)
/ /
Pregnancy claims:
• Date of delivery: / / Vaginal Cesarean
• If not delivered, expected delivery date: / /
• Please advise of any complications: