Continental American Insurance Company, which underwrites Aflac Group coverage, uses this claim when a group life insured asks for an accelerated death benefit. The attending physician completes Section B, stating the diagnosis, whether the patient is terminally ill with life expectancy in months, and which activities of daily living the patient cannot perform. The insured chooses a lump sum or periodic payment.
The insured completes Section A and the authorizations, and the signature page can require a spouse, owner, irrevocable beneficiary and notarized signature. The attending physician completes Section B on pages 2 and 3 and signs.
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Accelerated Death Benefit Claim Form (Aflac Group)
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Section B asks for the diagnosis and ICD-10 code, the nature and cause of the condition, when symptoms began, whether it has persisted at least 90 days, treatment dates and hospitalization, whether the patient is terminally ill with life expectancy in months, and which activities of daily living the patient cannot perform.
The instructions list the physician's information and signatures, medical records about the diagnosis, and the signed Authorization to Obtain Information. The insured's signature page also needs any required spouse, owner or irrevocable beneficiary signatures and a notarized signature.