HOW TO FILE ACCIDENT AFLAC CLAIM
Welcome to Summit Insurance Services! We are here to help you and your family
during this stressful time. Our services to you are at no cost to you or your employer.
In an effort to help expedite your claim we ask for your help in the following:
Step 1:
Please complete the attached “Accident Claim Form” and follow the check list guidelines below.
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Have the patient or policy holder complete and sign Page 1 & 2
Sign the Claim Authorization form
Sign Summit authorization form if necessary sign specialty care (St. John’s)
Police report (if a motor vehicle accident)
Death Certificate (if patient is deceased due to accident)
Step 2:
We at Summit Insurance understand that injuries can lead to difficult times, again we are here to help.
Please obtain and forward to us copies of the following items as you obtain them to expedite your
claim.
Gather and submit copies of the following: (as applicable)
 Initial visit to physician, ER, or Urgent Care’s encounter notes and detailed billing
 In-patient hospital bill showing dates admitted and room type
 Operative report (if surgery needed to correct injury)
 Follow-up visits (detailed billing)
 CT, MRI or EEG reports and billing(for policies issued after June 2006)
 Physical Therapy
 Appliance (crutches, wheelchair, leg brace etc)
 Prosthesis
 Ambulance
 Transportation & Lodging (if patient was hospitalized more than 100 miles from home)
Contact us at: 307-733-2055 or 800-261-7612
Email: [email protected]
Fax: 307-733-6178
AFLAC Customer Service Phone: 800-992-3522
HOW TO FILE AN AFLAC DISABILITY CLAIM
Welcome to Summit Insurance Services! We are here to help you and your family
during this stressful time. Our services to you are at no cost to you or your employer.
In an effort to help expedite your claim we ask for your help in the following:
Please complete the attached “Disability Claim Form” and follow the check list guidelines below.
Initial/First Claim for Disability
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Have the patient complete and sign page 1
Have the employer complete and sign page 2
Have your physician complete and sign page 3 & 4
Have the patient sign the Authorization form
If you are self-employed, send a copy of your current business license and most recent quarterly tax
records.
Continuing/Second and Subsequent Disability Claims
 Have the patient complete and sign page 1
 Have your physician complete and sign page 2
 Have your employer complete and sign page 3
Contact us at: 307-733-2055 or 800-261-7612
Email: [email protected]
Fax: 307-733-6178
AFLAC Customer Service Phone: 800-992-3522
HOW TO FILE AN AFLAC CANCER CLAIM
Welcome to Summit Insurance Services! We are here to help you and your family
during this stressful time. Our services to you are at no cost to you or your employer.
In an effort to help expedite your claim we ask for your help in the following:
Step1:
Please complete the attached “Cancer Claim Form” and follow the check list guidelines below:
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Have the patient complete and sign page 1
Sign the Aflac Authorization form
Sign Summit authorization form if necessary sign specialty care (St. John’s)
Pathology report diagnosing cancer.
Initial physician notes and detailed billing.
Step 2:
We at Summit Insurance understand that fighting cancer can be a daunting task, again we are here to
help. Please try to obtain and forward to us copies of the following items as you receive them to
expedite your claim.
 Gather and submit copies of the following bills (as applicable)
 In-patient hospital bill showing dates admitted and room type
 Operative report
 Anesthesia
 Ambulance
 Chemotherapy Treatment
 Radiation Treatment
 Experimental Treatment
 Stem Cell or Bone Marrow Transplantation
 Anti-Nausea drugs
 Immunotherapy
 Blood and Plasma transfusions during hospital confinement
 Transportation & Lodging (only if patient is receiving treatment more than 50 miles from
home)
 Extended-Care Facility, Home Health Care or Nursing Services
 Prosthesis
Contact us at: 307-733-2055 or 800-261-7612
Email: [email protected]
Fax: 307-733-6178
AFLAC Customer Service Phone: 800-992-3522
HOW TO FILE AN AFLAC HOSPITAL CLAIM
Form is used to file claims for the following AFLAC policies:
 Hospital Protection: In-patient Confinement, Out-patient Surgery, Invasive
diagnostic exams
 Hospital Intensive Care: In-patient intensive care confinement, ambulance,
organ transplant
 Personal Sickness: In-patient Confinement, major diagnostic exam, surgery
Welcome to Summit Insurance Services! We are here to help you and your family
during this stressful time. Our services to you are at no cost to you or your employer.
In an effort to help expedite your claim we ask for your help in the following:
Please complete the attached “Sickness Claim Form” and follow the check list guidelines below:
 Have the policy holder complete claim form
 Sign the Authorization form
Gather and submit copies of the following detailed bills and accompanying DR. notes (as
applicable)
 In-patient hospital bill showing dates admitted and room type
 Operative report
 Invasive diagnostic exams (colonoscopy, sigmoidoscopy, arthroscopy etc)
 Dr Visit
We can be reached at 307-733-2055 or 800-261-7612
Email: [email protected]
Fax: 307-733-6178
AFLAC Customer Service Phone: 800-992-3522
HOW TO FILE AN AFLAC CLAIM
Specified Health Event Claims
Please complete the attached “Accident Claim Form” and follow the check list guidelines below.
 Have the patient complete and sign page 1
 Have your physician complete and sign page 2 & 3
 Sign the Authorization form
Gather and submit copies of the following bills (as applicable)
 In-patient hospital bill showing dates admitted and room type
 Ambulance
 Continuing Care
 Transportation & Lodging (only if patient is receiving treatment more than 50 miles from
home)
HOW TO FILE AN AFLAC CLAIM
Dental Claims
All dental claims will need to be submitted on the attached American Dental Association (ADA) claim
form.
 Have the provider fill out the ADA claim form
 Sign the Authorization
IMPORTANT! If you want the payment to come directly to you, please be sure that box 37 is blank.
If you sign in this box or if the dentist puts “signature on file” then payment will be issued to the
dentist.
At Summit Insurance we are dedicated to ensuring that
your AFLAC claim goes as smoothly as possible. As
your AFLAC agents, we are here to answer your
questions and help you with the more complicated
issues.
We can be reached at 307-733-2055 or 800-261-7612
In an effort to assist you in submitting your AFLAC
claims for the fastest response, we have included:
□ Claim Form
□ Fax Cover Sheet
□ Authorization Form
For faster service fax your claims to 877-442-3522
AFLAC Customer Service Phone: 800-992-3522