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Empire Life GLB-0055-EN Group Life and AD Claim Form

Empire Life uses this four-page form for group life claims on insured employees and for accidental death claims. Page 4 is the attending physician statement, which records the primary and secondary causes of death, the onset of the last illness and first attendance, and any accident, suicide or homicide. One physician statement is needed per claim, even with several beneficiaries.

Who completes it

The attending physician completes the physician part of the page 4 statement and signs it with their certified specialty and stamp. The claimant completes the Claimant Statement and authorization, and the plan administrator completes the Group Policyholder Statement.

Submitting and payment

How to submit it
The completed statement goes to Empire Life's Life & Disability Claims in Group Solutions by mail, fax or email, as printed on page 4.
Who pays
Page 4 states that any cost incurred in completing the attending physician statement is the responsibility of the claimant.

Good to know

  • The physician statement is always required for accidental death claims and for employee life claims at or above the amount printed on the form; Empire Life may request it for other life claims.
  • Dependant life claims do not require a Claimant Statement, and each beneficiary completes a separate Claimant Statement when there are several.
  • A notice to the physician says the information may be disclosed to the claimant, and that providing it consents to the unedited release of its contents.
  • If death was due to an accident, suicide or homicide, the physician specifies which and describes it briefly; the form also asks for age at death or date of birth.

Get the official form

Download the current version from the source each time; forms change without notice.

Group Life and Accidental Death Insurance Claim Form

Official pagePDF

Fill it with Vero

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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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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Frequently asked questions

When does Empire Life need the attending physician statement for a group life claim?

Empire Life always requires it for accidental death claims and for insured employee life claims at or above the amount threshold printed on the form. For other life claims, Empire Life may request it. Only one physician statement is needed per claim, even when there are several beneficiaries.

Who pays for the Empire Life attending physician statement?

The claimant. Page 4 states that any cost incurred in completing the form is the claimant's responsibility, and the claimant signs an acknowledgement that they are responsible for any fees related to its completion, along with an authorization releasing the deceased's health information to Empire Life.

What does the physician complete on Empire Life form GLB-0055-EN?

Only the physician part of page 4: primary and secondary causes of death, the date of onset of the last illness, the date you first attended the deceased in that illness, age at death or date of birth, and, for an accident, suicide or homicide, which one with a brief description, then your details and signature.