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Cancellation of AFLAC Products

Complete this form only if you need to cancel all or some of your AFLAC products

First Name

Last Name

Street Address

City

State

Zip Code

I would like to cancel my subscription to the following AFLAC products. Please check the box of any AFLAC product you’d like to cancel. All changes will be effective January 1, 2023.

By placing my initials in the box below, I acknowledge that I currently have these products (i.e. through Aflac) and have decided not to continue my subscription at this time.

Please type your Full Name in the box below. By typing my name in this box, I acknowledge that I am using a typed signature in place of a written signature and that the information in this waiver pertains to me and is truthful and accurate to the best of my knowledge.