Health Benefit Forms

Attending Physicians Statement

Once you have applied for LTD Benefits, you may be required to complete the Attending Physician’s Initial LTD Benefits Statement before your LTD claim can be approved. A copy of this form can be obtained from the Plan Administrator.

Information Needed to Complete the Form

  • Your name and signature is needed to complete the form.
  • In addition, your doctor must provide detailed medical information related to your current condition and sign the form.
  • Please follow the instructions on the form.


  • You must complete the patient’s section of the form before forwarding to your doctor for completion.
  • Completed forms should be mailed directly to the insurer.
  • Questions on completing the form should be directed to the Plan Administrator.
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