Manulife and SISIP Financial request this supplementary statement when they need a medical update on an existing long term disability claim under Manulife group policies 901102, 911104 and 911105. The information the attending physician provides forms the basis on which continuing entitlement to benefits is assessed, so it centres on objective findings, functional classes, treatment, competency and fitness for vocational rehabilitation or return to work.
The attending physician completes Part II, sections 1 to 11, and signs the declaration in section 11. The patient/claimant completes Part I, including their Service Number and LTD claim number, and signs the declaration and authorization.
Download the current version from the source each time; forms change without notice.
Supplementary Attending Physician's Statement (APS) – Long Term Disability
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The patient/claimant. The completion instructions printed at the top of Part II state that any charge for completing the form is the patient/claimant's responsibility. The same instructions ask you to print your answers and return the form, with its attachments, to the claimant or directly to Manulife's SISIP Services department.
Section 2 rates physical functional impairment from Class 1, capable of heavy occupational activities, to Class 5, not capable of any type of gainful employment. Section 4 rates psychiatric impairment from Class 1, absent or minimal symptoms, to Class 4, severe symptoms and occupational dysfunction. Both ask you to describe the specific effects on the patient's present ability to work.
Section 7 asks whether, in your opinion, the patient is medically fit to take part in a vocational rehabilitation program or return to work, what supports would be needed if not, and whether the patient has expressed a desire to do so. Section 8 then asks whether any professional, driver's or other licence has been restricted, suspended or revoked.