AFLAC CANCELLATION NOTICE
Date: ________________________
I, ____________________________________________, do hereby request cancellation
(print name of insured)
of my ________________________________________ Policy __________________________.
(type of policy) (policy number)
I, ____________________________________________, do hereby request cancellation
(print name of insured)
of only my _____________________________________ rider on my
(type of rider)
____________________________________ policy, Policy No. __________________________.
(type of policy) (policy number)
Please make this cancellation effective ______________________________________.
(date)
Insured’s signature: ______________________________________________________
Insured’s SSN: __________________________________________________________
Associate/Agent: ________________________________________________________
(name and writing number)
American Family Life Assurance Company of Columbus (Aflac)
Worldwide Headquarters • 1932 Wynnton Road • Columbus, Georgia 31999
1.800.992.3522 telephone • 1.800.448.8922 fax • aflac.com
M0784 M0784.3
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