Family of condition-specific physician statements for group critical illness claims, including dependent children's covered illnesses.
- Completed by
- Treating physician
- Issued by
- The Co-operators
- Format
- Language
- English
Co-operators GL2439: Attendance Support Program APS
Co-operators Life uses this statement for its group Attendance Support Program, which looks at frequent absences and consistent attendance at work. The physician is asked whether they knew about the patient's frequent absences, whether an ongoing condition affects consistent attendance, and whether attendance is expected to improve. The current version is GL2439, dated 09/24.
Who completes it
The plan member completes the plan member information and authorization section. The treating physician completes the Medical Information section and signs the physician acknowledgement.
Submitting and payment
- How to submit it
- Return the completed form to Co-operators Life Insurance Company's Disability Claims Department by email or fax, or mail the original.
- Who pays
- The form states that the plan member is responsible for any charge for completing it or for providing related medical information.
Good to know
- Include copies of chart notes, test results and consultation reports from the past year with the completed form.
- The form asks whether the patient gave you documentation of days absent, whether the condition is chronic, and whether you know the duties of their occupation.
- A separate question asks for social or other non-medical factors that may affect the patient's ability to attend work regularly.
- For prescriptions, give the current dose and the date each drug was started or changed, along with treatment providers and examination dates.
Get the official form
Download the current version from the source each time; forms change without notice.
Attendance Support Program – Attending Physician Statement
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.
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.
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Frequently asked questions
What does the Co-operators Attendance Support Program form focus on?
Consistent attendance at work. The physician describes restrictions and limitations that affect the patient's ability to attend work consistently, lists any social or non-medical factors, and gives a prognosis on whether attendance is expected to improve in the foreseeable future, with an estimated time frame.
Who will see the information on the attendance support statement?
By signing, the physician acknowledges that the statement is kept in a disability benefits file with the plan insurer and might be accessible to the patient, to third parties granted access, or to those authorized by law. The plan member authorizes release to the plan administrator, plan adjudicator and insurer.