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Continental American Insurance Company (CAIC) / Aflac Group Critical Illness Claim Form (with Attending Physician’s Statement, HIPAA Authorization to Obtain Information, and Electronic Funds Transaction Authorization), page 1
Complex · 67/100Form Complexity Index

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What this form asks for

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This is the official claim packet used by Continental American Insurance Company (CAIC), an Aflac Group insurer, for filing a Critical Illness insurance claim. It collects policyholder and patient details, the qualifying diagnosis/event information, and an Attending Physician’s Statement to medically substantiate the claim. The packet also includes a HIPAA Authorization allowing CAIC/Aflac to obtain medical records needed to evaluate eligibility and benefits, plus an optional Electronic Funds Transaction (direct deposit) form to receive payments. Completing all sections and attaching the correct supporting records helps prevent processing delays and reduces the risk of denial for insufficient documentation.
Fillable fields139
Pages8
Sections45
Tables and lists1
Questions that depend on earlier answers28
Form Complexity IndexComplex, 67/100

The AI checks your answers before you download

16 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Policy/Certificate Number Presence and Administering Entity Eligibility

Validate that a Policy/Certificate Number is provided and that it matches the eligibility rule stated on the EFT section: if the policy number contains both letters and numbers (e.g., 0Y123B45), the request must be routed to Aflac (not CAIC) and CAIC direct deposit cannot be processed. This prevents misrouting and processing delays caused by submitting to the wrong administrator. If the format indicates an Aflac-administered policy, the submission should be rejected or redirected with clear instructions and the correct link.

Policyholder/Claimant Required Demographics Completeness

Ensure required policyholder fields are completed: Employer’s Name, Policyholder’s Name, Policy/Certificate No., Date of Birth, Gender, Address (including City/State/ZIP), and Telephone Number. These fields are necessary to identify the insured, match coverage, and contact the claimant for missing information. If any required field is missing, the claim should be flagged as incomplete and held for follow-up before adjudication.

SSN Format Validation (Policyholder/Claimant)

Validate that the Social Security Number, when provided, is exactly 9 digits (optionally allowing hyphens in the ###-##-#### pattern) and is not an obviously invalid value (e.g., all zeros). SSN is used for identity matching and to reduce duplicate records. If the SSN fails validation, the system should reject the value and request correction or allow submission only if SSN is truly optional for that section.

Date Field Format and Realism Checks (All Dates)

Validate that all dates (DOBs, diagnosis dates, symptom onset, admitted/discharged, signature dates, expected return-to-work dates) are in a valid date format and represent real calendar dates. Also enforce realism rules (e.g., DOB not in the future; admission/discharge not before DOB; signature dates not in the future beyond a small tolerance if allowed). If invalid or unrealistic, the submission should be blocked or routed to exception handling to prevent downstream calculation and eligibility errors.

Policyholder vs Patient Relationship Consistency

Require Patient’s Name, Relationship to Policyholder, Patient DOB, and Patient Gender when the patient is not the policyholder, and ensure the relationship selection is present and plausible. This is critical for dependent coverage validation and for determining who must sign HIPAA (adult dependent vs minor). If relationship or patient identifiers are missing/inconsistent, the claim should be marked incomplete and the correct signer requirements should be enforced.

Phone Number Format Validation (Claimant and Physician)

Validate telephone numbers for the policyholder and attending physician using a consistent rule (e.g., 10 digits for US numbers, allowing common punctuation). Accurate phone numbers are essential for obtaining missing documentation and clarifying medical details. If a phone number is invalid, the system should prompt for correction and prevent submission if the phone is required for that section.

And 10 more checks
  • Email Address Format and Consent Capture
  • Signature Presence and Wet-Signature Requirement Enforcement
  • HIPAA Authorization Correct Signer Logic (Adult Dependent/Minor/Representative)
  • Attending Physician Statement Minimum Completeness
  • Condition-Specific Documentation Requirement Validation
  • Myocardial Infarction Criteria Logical Consistency
  • Hospitalization and Confinement Date Logic
  • Work Status and Return-to-Duty Date Consistency
  • EFT (Direct Deposit) Selection and Banking Field Validation
  • Duplicate Identity and Cross-Form Consistency (Names/DOB/Certificate #)

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How to Fill Out CAIC Critical Illness Claim Form Online for Free in 2026

What the AI walks you through.

  1. Confirm you have the correct administrator/form (this packet is for Aflac Group/CAIC; verify your policy/certificate number and review your policy for covered benefits).
  2. Complete the Policyholder/Claimant Information section (employer, policy/certificate number, contact details, patient information, relationship, and any address change).
  3. Identify the critical illness condition/event being claimed and gather the required supporting medical documentation (e.g., chart notes/admission-discharge paperwork, operative/surgical report, pathology report, imaging/ER/cardiology records, dialysis start proof, etc., as applicable).
  4. Have the treating provider complete and sign the Attending Physician’s Statement (Page 1–2), including diagnosis dates, clinical criteria questions, restrictions/limitations, hospitalization details, and return-to-work expectations.
  5. Complete and sign the HIPAA Authorization to Obtain Information (AGC06106_2016); ensure the correct person signs (adult dependent signs for themselves; parent/guardian signs for a minor; legal representative signs if applicable).
  6. If you want direct deposit, complete the Electronic Funds Transaction Authorization, attach a voided check or bank direct deposit form, and sign (note: forms without signatures will not be processed; electronic signatures not accepted).
  7. Review fraud warnings, sign and date all required signature lines (policyholder/patient/physician as applicable), then submit the packet and attachments by email to [email protected] or fax to 1-866-849-2970.

Common Mistakes in Completing CAIC Critical Illness Claim Form

The ones the AI is built to catch.

Leaving required policyholder/claimant fields blank or partially filled
People often skip “basic” identifiers (Employer’s Name, Policy/Certificate No., SSN, DOB, gender, address, phone) because they assume Aflac can look them up. Missing or incomplete identifiers can prevent the claim from being matched to the correct certificate and will commonly trigger follow-up requests and processing delays. To avoid this, complete every field in the Policyholder/Claimant section and double-check that the policy/certificate number and employer name match your enrollment materials.
Confusing the policyholder with the patient (or mixing their information)
This form collects information for both the policyholder and the patient, and many claimants accidentally enter the patient’s details in the policyholder fields (or vice versa), especially when the patient is a spouse or child. This can cause eligibility verification issues, incorrect benefit payee determination, and delays while the insurer clarifies who is covered. Avoid this by confirming who the certificate holder is, then completing the patient section separately with the correct relationship and demographics.
Not submitting the correct medical documentation for the specific condition
Claimants frequently send generic records (e.g., a single office visit note) instead of the condition-specific documents listed (pathology report for cancer, discharge summary and cath report for heart attack, MRI/CT for stroke, operative report for bypass/transplant, dialysis start proof for renal failure). When the required evidence is missing, the claim is typically pended until the right records arrive. Use the checklist on the form and submit the exact reports named for your diagnosis, ideally including admission/discharge paperwork if hospitalized.
Providing the wrong “date of diagnosis” (using visit date instead of the form’s definition)
Several sections define diagnosis dates very specifically (e.g., cancer date is when the pathological specimen was obtained; heart attack date is when all criteria were met; renal failure date is when dialysis is recommended). People often enter the first appointment date, the date they were told verbally, or the billing date, which can affect benefit eligibility and timing. To avoid issues, follow the form’s definition and have the provider confirm the correct date from the medical record.
Submitting a stroke claim without proof of permanent neurological damage or including excluded events
The form states that stroke does not include TIAs or vertebrobasilar ischemia and requests neuroimaging plus proof of permanent neurological damage. Claimants often submit only an ER note or a CT report without follow-up documentation, or they file for a TIA believing it qualifies. This commonly results in denial or a request for additional records. Confirm the diagnosis meets the policy definition and include initial imaging, discharge summary, and follow-up neurologist/therapy notes documenting lasting deficits.
Attending Physician Statement left incomplete or filled out by the claimant
The Attending Physician’s Statement contains clinical criteria (EKG findings, enzyme levels, diagnostic studies, dialysis frequency, restrictions/limitations) that are often left blank or guessed by the claimant. Incomplete physician sections can stop adjudication because the insurer cannot confirm the covered event. Ensure the treating provider completes all applicable questions, attaches the requested reports, and signs/prints their name, degree, contact information, and medical ID number.
Missing signatures and dates (policyholder, patient, physician, HIPAA, EFT)
A very common delay is forgetting to sign and date the claim certification, patient signature line, physician signature, or the HIPAA authorization. The EFT form also states that forms received without signature will not be processed and that electronic signatures are not accepted. To avoid resubmission, sign in ink where required, date every signature line, and confirm the correct person signs (patient vs. policyholder vs. legal representative).
HIPAA authorization signed by the wrong person (adult dependent/minor rules ignored)
When records are for an adult dependent (spouse or child over 18), that dependent must sign the HIPAA; for a minor child, a natural parent or legal guardian must sign. People often have the policyholder sign everything, which can be invalid for releasing the dependent’s medical records. This can prevent the insurer from obtaining needed documentation and stall the claim. Verify whose records are being requested and obtain the correct signature (and legal representative details if applicable).
Incorrect or incomplete direct deposit (EFT) details and missing voided check/bank form
Claimants frequently transpose routing/account numbers, omit the account type (checking/savings), or forget the required voided check/direct deposit form. The form warns that incomplete or inaccurate information will not be processed, which can delay payment even after the claim is approved. To avoid this, copy numbers directly from a check or bank letter, include the supporting document, and confirm the routing number is 9 digits.
Submitting the EFT form for an ineligible policy number (letters + numbers)
The EFT section includes a critical note: do not complete this form if the policy number contains both letters and numbers (e.g., 0Y123B45) because those are administered by Aflac, not Aflac Group (CAIC). People miss this and send EFT requests to the wrong administrator, resulting in rejection and lost time. Check your policy number format first; if it contains letters and numbers, use the Aflac direct deposit registration site listed on the form instead.
Sending the claim to the wrong destination or omitting attachments when emailing/faxing
Because the form allows email or fax submission, claimants sometimes send only the claim pages without the supporting documentation, or they email/fax to a different Aflac address/number found online. Missing attachments or misdirected submissions lead to “no record received” situations or requests to resend documents. Use only [email protected] or fax 1-866-849-2970, and attach all required reports in the same transmission with clear file names (e.g., ‘DischargeSummary.pdf’, ‘PathologyReport.pdf’).

Frequently Asked Questions About CAIC Critical Illness Claim Form

 

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How does the AI fill out CAIC Critical Illness Claim Form?
You answer a few questions in plain words, or upload a document you already have. The AI reads what you give it and puts each answer into the right field of CAIC Critical Illness Claim Form, on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.
What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is CAIC Critical Illness Claim Form to fill out?
CAIC Critical Illness Claim Form has a Form Complexity Index of 67 out of 100, in the complex tier: 139 fillable fields across 8 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is this Critical Illness Claim Form used for?
This form is used to file a Critical Illness claim with Continental American Insurance Company (CAIC), part of the Aflac family, to request benefits for covered critical illness events. You should review your policy to confirm which conditions and services are covered under your plan.
Who needs to complete this claim form?
The policyholder/claimant completes the Policyholder/Claimant Information section and signs the form. Your healthcare provider must complete and sign the Attending Physician’s Statement, and you must also submit the signed HIPAA authorization to prevent delays.
Where do I send the completed claim form and documents?
Email the form and supporting documents to [email protected] or fax them to 1-866-849-2970. If you need help, you can call (800) 433-3036.
What supporting medical documentation is required with my claim?
Submit medical documentation that supports the diagnosis and treatment, such as chart notes and (if applicable) admission/discharge paperwork for a hospital stay, surgical/operative reports, and pathology reports for malignant conditions. Missing documentation is a common reason claims are delayed.
What documents are required for a cancer or carcinoma in situ claim?
You must submit the pathology report used to diagnose the condition. The physician section also asks for the date the pathological specimen(s) were obtained and whether the diagnosis was pathological or clinical.
What documents are required for a heart attack (myocardial infarction) or sudden cardiac arrest claim?
Provide the discharge summary, cardiology consult report, cardiac catheterization report, history & physical, and ER notes. The physician may also need to attach EKGs and lab reports showing elevated cardiac enzymes, as listed on the form.
What documents are required for coronary artery bypass surgery or a transplant claim?
For coronary artery bypass surgery, submit the operative report for the procedure. For major organ transplant or bone marrow transplant, submit the operative report as well.
What documents are required for a stroke claim, and are TIAs covered?
Submit the discharge summary and MRI and/or CT reports from the initial diagnosis, plus proof of permanent neurological damage (such as follow-up imaging and neurologist/therapist office notes). The form states that stroke does not include transient ischemic attacks (TIAs) or certain other conditions.
What documentation is needed for renal failure (end stage renal disease)?
Provide proof of the dialysis start date or the operative report for a kidney transplant. The End Stage Renal Disease Medical Evidence Report is preferred, and the form asks for the date a physician recommended dialysis begin.
Do benefits get paid to me or to my doctor/hospital?
Benefits are payable to the policyholder unless CAIC receives written authorization to assign benefits to the provider. If you want to assign benefits, attach a signed written request (benefit assignment).
Do I have to sign the HIPAA authorization, and who should sign it?
The form instructs you to return the signed HIPAA to prevent processing delays, because it allows CAIC/Aflac to obtain needed medical information. If the records are for an adult dependent (such as a spouse or a child over 18), that dependent must sign; for a minor child, a parent or legal guardian signs.
How do I report a permanent address change on the claim form?
In the Policyholder/Claimant Information section, enter the new address and check the box indicating it is a permanent address change. This helps ensure claim correspondence is sent to the correct location.
Can I choose to receive claim communications electronically by providing my email address?
Yes. The form states that by providing your email address, you consent to the use of electronic transactions and communications related to your CAIC policies and claims to the extent permitted by law.
How do I set up direct deposit for my claim payment, and what do I need to include?
Complete the Electronic Funds Transaction Authorization and select Start/Stop/Change, then provide the routing number, account number, and bank details. You must include a blank voided check or a direct deposit form from your financial institution, and the form must be signed (forms without signatures will not be processed).
Are electronic signatures accepted on the direct deposit form?
No. The direct deposit authorization specifically states that electronic signatures are not accepted and that forms received without a signature will not be processed.
What if my policy number contains both letters and numbers—should I use this form?
No. The direct deposit section notes that if your policy number has both letters and numbers (for example, 0Y123B45), it is administered by Aflac (not Aflac Group/CAIC), and CAIC cannot process the direct deposit request; you must use the Aflac direct deposit registration site listed on the form.
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