American Family Life Assurance Company of Columbus (Aflac) Series A36000 Accident Advantage Premium Rates. Payroll
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1 Payroll Option 1 Policy Series A36100 Industry A Industry B Industry C Industry D/E Industry A Industry B Industry C Industry D/E Name Insured/ Spouse Industry A Industry B Industry C Industry D/E Industry A Industry B Industry C Industry D/E Option 2 Policy Series A36200 Industry A Industry B Industry C Industry D/E Industry A Industry B Industry C Industry D/E Name Insured/ Spouse Industry A Industry B Industry C Industry D/E Industry A Industry B Industry C Industry D/E MRS097 American Family Life Assurance Company of Columbus (Aflac) Worldwide Headquarters: Columbus, Georgia MRS097.1
2 Payroll Option 3 Industry A Industry B Industry C Industry D/E Industry A Industry B Industry C Industry D/E Name Insured/ Spouse Industry A Industry B Industry C Industry D/E Industry A Industry B Industry C Industry D/E Option 4 Policy Series A36400 Industry A Industry B Industry C Industry D/E Industry A Industry B Industry C Industry D/E Name Insured/ Spouse Industry A Industry B Industry C Industry D/E Industry A Industry B Industry C Industry D/E MRS097 2 MRS097.1
3 Payroll - Off-the-Job Only Option 3 Industry A Industry B Industry C Industry D/E Industry A Industry B Industry C Industry D/E Name Insured/ Spouse Industry A Industry B Industry C Industry D/E Industry A Industry B Industry C Industry D/E Union Industry A/B/C/D/E Option 1 Option 2 Policy Series A36100 Policy Series A Name Insured/ Spouse Name Insured/ Spouse Option 3 Option 4 Policy Series A Name Insured/ Spouse Name Insured/ Spouse MRS097 3 MRS097.1
4 Association Option 1 Policy Series A36100 Industry A Industry A Industry B Industry B Industry C Industry C Industry D/E Industry D/E Industry A Industry A Industry B Industry B Industry C Industry C Industry D/E Industry D/E Option 2 Policy Series A36200 Industry A Industry A Industry B Industry B Industry C Industry C Industry D/E Industry D/E Industry A Industry A Industry B Industry B Industry C Industry C Industry D/E Industry D/E Note: All associations will be given a "C" rate unless an exception is approved. MRS097 4 MRS097.1
5 Association Option 3 Industry A Industry A Industry B Industry B Industry C Industry C Industry D/E Industry D/E Industry A Industry A Industry B Industry B Industry C Industry C Industry D/E Industry D/E Option 4 Policy Series A36400 Industry A Industry A Industry B Industry B Industry C Industry C Industry D/E Industry D/E Industry A Industry A Industry B Industry B Industry C Industry C Industry D/E Industry D/E Note: All associations will be given a "C" rate unless an exception is approved. MRS097 5 MRS097.1
6 Payroll Additional Accidental-Death Benefit Rider (Series A36050) Ages Industry A/B/C/D/E Industry A/B/C/D/E Name Insured/ Spouse Industry A/B/C/D/E Industry A/B/C/D/E Lump Sum Critical Illness Benefit Rider (Series CIRIDER) Lump Sum Critical Illness Conversion Policy (Series CIR100) Ages Issue Type Age Band Monthly Quarterly Semiannual Annual 8-Month 9-Month 10-Month Biweekly Semimonthly Weekly Parent Primary & Spouse Parent Lump Sum Critical Illness Benefit Rider (Series CIRIDERH) Lump Sum Critical Illness Conversion Policy (Series CIR100H) Ages Issue Type Age Band Monthly Quarterly Semiannual Annual 8-Month 9-Month 10-Month Biweekly Semimonthly Weekly Parent Primary & Spouse Parent MRS097 6 MRS097.1
ACCIDENT-ONLY INSURANCE (A36000 Series)
ACCIDENT-ONLY INSURANCE (A36000 Series) Application to: American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters Columbus, Georgia 31999 Please Print in Black
Please Print in Black Ink To Be Completed by Proposed Insured. Proposed Insured s Name Last First MI. DOB Sex SSN - - City State ZIP
Application for Cancer Indemnity Insurance (A78000 Series) Application to: American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters Columbus, Georgia 31999
Please Print in Black Ink To Be Completed by Proposed Insured Proposed Insured s Name Last First MI. DOB Sex SSN - - Month/Day/Year
SHORT-TERM DISABILITY INSURANCE (A57600 Series) Application to: American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters Columbus, Georgia 31999 New Conversion
Please Print in Black Ink To Be Completed by Proposed Insured/Employee Proposed Insured s/employee s Name Last First MI
Application for Short-Term Disability Insurance (A57600 Series) Application to: American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters Columbus, Georgia
Proposed Insured s/employee s Name Last First MI. DOB Sex SSN - -
SPECIFIED HEALTH EVENT PROTECTION INSURANCE POLICY (A71000 Series) Supplemental Health Insurance Coverage Application to: American Family Life Assurance Company of Columbus (Aflac) Worldwide Headquarters
Medical Plan with Basic Vision. Medical Plan with Basic Vision
Full-time, $13.45 per hour or less Basic Only $89.00 $39.00 $91.58 $41.58 + Child $112.00 $62.00 $116.67 $66.67 + * + $133.00 $83.00 $137.67 $87.67 $150.00 $100.00 $154.67 $104.67 *Family $196.00 $146.00
WORCESTER POLYTECHNIC INSTITUTE
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Medical Plan with Basic Vision. Medical Plan with Basic Vision
Contribution Summary Full-time, $13.45 per hour or less Basic Only $89.00 $39.00 $91.58 $41.58 + Child $112.00 $62.00 $116.67 $66.67 + * + $133.00 $83.00 $137.67 $87.67 $150.00 $100.00 $154.67 $104.67
Please Print in Black Ink To Be Completed by Proposed Insured. Proposed Insured s Name Last First MI. DOB Sex SSN - - City State ZIP
Application for Supplemental Limited Benefit Specified Disease, Cancer Indemnity Insurance (Policy Forms A78100PA, A78200PA, A78300PA and A78400PA) Application to: American Family Life Assurance Company
Please Print in Black Ink To Be Completed by Proposed Insured/Employee. Proposed Insured's/Employee s Name Last First MI.
Application for Accident Insurance (A35000 Series) Application to American Family Life Assurance Company of Columbus (Aflac) Worldwide Headquarters Columbus, Georgia 31999 New Conversion Additional Units
Proposed Insured s Name Last First MI. DOB Sex SSN - - Month/Day/Year. City State ZIP. Telephone ( ) Home Work Cell
SPECIFIED HEALTH EVENT INSURANCE POLICY (Series A74000) Supplemental Health Insurance Coverage Application to: American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide
THIS IS A LIMITED BENEFIT POLICY. YOU SHOULD HAVE COMPREHENSIVE HEALTH COVERAGE BEFORE PURCHASING THIS POLICY.
SPECIFIED HEALTH EVENT INSURANCE POLICY (Series A74000) Limited Benefit Supplemental Health Insurance Coverage Application to: American Family Life Assurance Company of Columbus (herein referred to as
Payroll Account Acknowledgment All applicable sections must be completed for processing.
Payroll Account Acknowledgment All applicable sections must be completed for processing. INSTRUCTIONS ALL accounts must complete Section 9, the Authorization and Signatures section. Accounts establishing
Please Print in Black Ink To Be Completed by Proposed Insured/Employee. Proposed Insured's Name DOB Sex Last First MI Month/Day/Year
HOSPITAL CONFINEMENT INDEMNITY INSURANCE POLICY (A46000 Series) Application to: American Family Life Assurance Company of Columbus (Aflac) Worldwide Headquarters Columbus, Georgia 31999 New Conversion
NOTE: If applicable, the term "insured" also means "annuitant," and the term "policy" also means "contract."
REQUEST FOR LIFE POLICY CHANGE/BENEFICIARY CHANGE Application to American Family Life Assurance Company of Columbus (Aflac) Worldwide Headquarters: Columbus, Georgia 31999 INSTRUCTIONS: 1. Complete a separate
Payroll Account Acknowledgment
Payroll Account Acknowledgment All applicable sections must be completed for processing. INSTRUCTIONS ALL accounts must complete Section 9, the Authorization and Signatures section. Accounts establishing
Form A57625RCA 2 A57625RCA Aflac All Rights Reserved
American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters 1932 Wynnton Road Columbus, Georgia 31999 1.800.99.AFLAC (1.800.992.3522) This is a supplement to
Payroll Account Acknowledgment All applicable sections must be completed for processing.
Payroll Account Acknowledgment All applicable sections must be completed for processing. INSTRUCTIONS ALL accounts must complete Section 8, Authorization and Signatures. Accounts establishing or modifying
Driver s License Number State of Issue State of Birth. City State ZIP
SHORT-TERM DISABILITY INSURANCE (A57600 Series) Application to: American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters Columbus, Georgia 31999 New Conversion
Please Print in Black Ink To Be Completed by Proposed Insured Proposed Insured s Name Last First MI. DOB Sex SSN - - Month/Day/Year
SHORT-TERM DISABILITY INSURANCE (A57600 Series) Application to: American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters Columbus, Georgia 31999 New Conversion
Please Print in Black Ink To Be Completed by Proposed Insured. Proposed Insured s Name Last First MI. DOB Sex SSN - - City State ZIP
Application for Specified Disease Insurance (A78000 Series) Application to: American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters Columbus, Georgia 31999
Please Print in Black Ink To Be Completed by Proposed Insured. Proposed Insured s Name Last First MI. DOB Sex SSN - - Month/Day/Year.
Application for Hospital Confinement Indemnity Insurance (B40000 Series) Application to: American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters Columbus,
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Please Print in Black Ink To Be Completed by Proposed Insured/Employee. Last First MI DOB Sex SSN - -
Application for Cancer Indemnity Insurance (A76000 Series) Application to: American Family Life Assurance Company of Columbus (Aflac) Worldwide Headquarters Columbus, Georgia 31999 New Conversion Policy
Aflac Life Solutions. We ve been dedicated to helping provide peace of mind and financial security for nearly 60 years.
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Application for Accident Insurance (A35000 Series) Application to American Family Life Assurance Company of Columbus (Aflac) Worldwide Headquarters Columbus, Georgia 31999 New Conversion Policy Number
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REQUEST FOR CHANGE/APPLICATION FOR REINSTATEMENT AND/OR ADDITIONS HOSPITAL INTENSIVE CARE PROTECTION INSURANCE POLICY ATTENTION: POLICYHOLDER SERVICES (PHS) American Family Life Assurance Company of Columbus
Please Print in Black Ink To Be Completed by Proposed Insured/Employee Proposed Insured s/employee s Name Last First MI
Application for Short-Term Disability Insurance (A57500 Series) Application to American Family Life Assurance Company of Columbus (Aflac) Worldwide Headquarters Columbus, Georgia 31999 New Conversion Additional
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Please Print in Black Ink To Be Completed by Proposed Insured. Last First MI DOB Sex SSN - - Address Street or Post Office Box
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