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Public Service DI Plan: Initial DI Medical Statement

Federal public servants claiming long-term disability benefits under the Public Service Disability Insurance (DI) Plan, policy 12500-G, need this statement from their attending physician. It is the CLHIA universal industry form and replaced the plan's three separate Attending Physician Questionnaires. Sun Life, which administers DI claims, assesses it together with the employee, manager/supervisor and compensation advisor statements.

Who completes it

The attending physician, or the applicable treating medical provider, completes the medical statement section. The employee completes the patient information and consent section, and the immediate manager/supervisor and compensation advisor each complete a separate statement.

Submitting and payment

How to submit it
The form is downloaded from Sun Life's DI webpage, and Sun Life's Employee Claim Guide explains how to submit the claim. Treasury Board advises confirming DI Plan membership through MyGCPay, the Pay Centre or the departmental compensation office first to avoid delays.

Good to know

  • DI benefits apply when an illness or injury is expected to last beyond the 13-week elimination period, or once sick leave is exhausted, whichever is later.
  • The retired questionnaires covered musculoskeletal, mental health and other medical conditions; Treasury Board says the single form was adopted to reduce the administrative burden on attending physicians.
  • Sun Life still accepts a claim submitted on one of the three previous Attending Physician Questionnaires, and the claim will still be assessed.
  • The DI Plan is a mandatory plan providing 70% income replacement when a totally disabling illness or injury keeps a member off work for long periods.

Get the official form

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

Initial Disability Insurance Medical Statement

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it 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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How this list is checked

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Does Sun Life still accept the old DI Plan physician questionnaires?

Yes. Treasury Board's notice says Sun Life will accept a claim submitted on one of the three previous Attending Physician Questionnaires (Musculoskeletal, Mental Health or Other Medical Conditions) and will still assess it. The Initial Disability Insurance Medical Statement is the single CLHIA industry form that replaced them.

When does a DI Plan claim need this medical statement?

The DI Plan covers an illness or disability expected to last beyond the 13-week elimination period, or beyond the exhaustion of sick leave, whichever is later. The medical statement is the attending physician's part of that claim and is submitted with the employee, immediate manager/supervisor and compensation advisor statements, which remain unchanged.

Who do physicians contact with questions about a DI Plan claim?

Sun Life. Treasury Board directs plan members and attending physicians with questions about a claim to Sun Life, which administers claims under policy 12500-G. The medical statement, the other claim forms and the Employee Claim Guide are all reached through Sun Life's DI webpage.