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.

Notes

• 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.