Continental American Insurance Company uses this nine-page packet when an employee with Aflac Group life insurance becomes disabled and asks to have premiums waived. The attending physician's statement on pages 8 and 9 covers history, diagnoses with codes, objective findings, treatment dates, progress, functional capacity and a return-to-work plan. The employee, employer and physician each complete their own statement.
The employee completes the Employee's Statement and signs the release authorization, and the employer completes the Employer's Statement. The treating physician completes the Attending Physician's Statement and returns it to the patient.
Download the current version from the source each time; forms change without notice.
Life Waiver of Premium Claim (Aflac Group)
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The statement says it must be filled in completely by a physician without expense to the insurance company, so Aflac does not pay for completion. The physician completes the statement and returns it to the patient, who submits the full packet to Aflac.
The statement ends with an instruction to return the completed form to the patient or employee. The employee gathers the employee, employer and physician statements and the signed authorization and sends them to Aflac's claims team using the contacts in the filing instructions.