Desjardins Insurance uses this one-page statement when a group life insurance death claim needs the physician's account of the death. It records the place and date of death, the condition directly leading to death and its antecedent causes, attendance and diagnosis dates, whether an inquest or autopsy took place, five years of treatment history and tobacco use.
The attending physician completes Section B (physician's statement) and Section C (identification, licence number, general practitioner or specialist, and signature). The claimant fills in the employee and contract details and Section A on the deceased.
Download the current version from the source each time; forms change without notice.
Death claim – Physician's statement
Déclaration du médecin traitant pour un décès
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.
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Not the physician's part. The form notes that information about the diagnosis should be provided by the attending physician, so that section cannot be filled in online. The physician completes the statement and identification sections and signs, indicating whether they are a general practitioner or a specialist.
Question 1 asks for the disease or condition directly leading to death, meaning the disease, injury or complication rather than the mode of dying. Question 2 lists antecedent causes, and question 3 other significant conditions that contributed to the death without being related to the condition causing it.
The claimant. A notice on the form states that fees charged for this statement are to be paid by the claimant. The completed statement accompanies the beneficiary's and employer's statements, and Desjardins accepts claim documents by secure online upload or by mail.