Aflac Employee Interest Form
Hello! Thanks for showing interest in the Aflac benefits. Whether you're looking to learn more, enroll into coverage, or need help with claims please fill out this form and Nando, your Aflac rep. will be able to assist you momentarily.
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Email *
What do you want to do? *
Required
aflac pays you cash
Why Aflac ?
Employer Name
Work Location
Work Position
First Name *
Last Name *
Date of Birth *
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/
DD
/
YYYY
Phone Number(Cell) *
When's a good day and time for a phone call, virtual call, or in person meet up? *
Looking for Coverage?
Clear selection
Interested Plan
Disclaimer: Based on your Employer, some of these plans may not be available to you. I apologize for the inconvenience.
How I wish to enroll
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