Canada Life uses this certificate for the physician's part of an individual accident claim for dismemberment or specific loss, such as an amputation or the loss of sight, hearing, speech or use of a limb. It records the accident, treatment dates, the exact level of any amputation on body diagrams, the possibility of improvement and whether the injury alone caused the loss.
The attending physician completes the whole certificate and signs it with their specialty and contact details. The claimant completes the separate Individual Health Claim for Accidental Death, Dismemberment or Specific Loss claimant's statement (M5980).
Download the current version from the source each time; forms change without notice.
Certificate of Attending Physician – Dismemberment or Loss
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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It depends on the loss. Amputations need the surgery report and hospital admittance and discharge summary; loss of sight needs visual acuity results and an ophthalmologist report; hearing loss needs an audiologist report and hearing test; speech loss a speech therapy assessment; and loss of use needs range of motion and therapy reports.
Canada Life asks that, once both parts of the claim are completed, a scanned copy be sent by email or fax, and that the forms not be mailed. The form can be printed, or completed in Adobe Reader XI or higher rather than a browser and saved.
Yes. It asks whether the injured limb functioned normally before the accident, the vision in each eye or the hearing before the accident if known, and whether speech was intelligible beforehand. Question 6 asks whether the injury described was solely responsible for the loss and, if not, for any contributing causes.