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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