Members of the federal Public Service Management Insurance Plan (PSMIP) need this statement from their doctor to claim long-term disability benefits from iA Financial Group under contract G-2400. It is the CLHIA standard form and one of four documents in the claim, along with the employee, manager/supervisor and compensation advisor statements. iA advises sending the claim about two months before the elimination period ends.
The doctor, or applicable medical provider, completes Section 2 (Medical Statement) and signs it with their specialty and licence or registration number. The patient completes and signs Section 1, which lists current medications, height, weight and dominant hand and gives consent.
Download the current version from the source each time; forms change without notice.
Initial Disability Insurance Medical Statement
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.
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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iA advises sending the claim about two months before the end of the elimination period, which is 13 weeks or the exhaustion of sick leave, whichever is later. Claims can still be submitted up to three months after the elimination period ends, but iA says claims received after that may be denied.
Not always. A stop sign on page 3 tells you to stop and sign the end of the form if the patient has returned to work or the disability will last less than 4 weeks. For disabilities expected to exceed 4 weeks, complete all pages, including investigations, clinical findings, restrictions and limitations, prognosis and return-to-work goals.
The patient. A notice at the top of the form and the consent in Section 1 both state that the patient is responsible for any fees related to completing it. The consent also authorizes release of consultation reports, clinical notes, test results and hospital records, but excludes genetic test results.