FY24 AFLAC Enrollment

Affac.
PREMIUM DEDUCTION AUTHORIZATION/WAIVER OF PARTICIPATION
Last*
First*
MI
SSN (last four)
Phone
WAIVER OF PARTICIPATION
(if Not Applying. Sign Here) - I understand that these policies are offered through my employer by payroll deduction and am waiving my participation based on one of the following:
I am NOT currently participating in the offerings by my employer, including products offered by AFLAC and waive my opportunity to participate at this time.I currently have these products (i.e. through ALFAC) and have decided not to upgrade to any newer policies at this time.
I certify that the features and benefits of Aflac's guaranteed-renewable insurnace policies and other products offered to me by my employer have been explained to me completely.
EMPLOYEE'S SIGNATURE*

Clear
DATE*

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Date
Should be Empty:

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