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Co-operators GL2325: Critical Disease Physician Form

Co-operators Life Insurance Company asks the treating physician for this two-page statement when a plan member claims a group critical disease benefit. It records the primary and secondary diagnoses, who made the diagnosis and when, the investigations behind it, current treatment and the patient's response. The completed statement goes to the insurer's Group Life Claims Department with the chart notes, test results and consultation reports it asks you to attach.

Who completes it

The physician providing treatment completes Section 2, Medical Information, and signs Section 3, the physician acknowledgement and authorization. The plan member completes Section 1 with their group, account and certificate numbers and signs an authorization releasing medical information to the plan administrator, plan adjudicator and insurer.

Submitting and payment

How to submit it
The completed form must be emailed or faxed to Co-operators directly from the physician's office, or the original can be mailed to the Group Life Claims Department at the address printed on the form.
Who pays
The plan member is responsible for the cost of completing this form, and their signed authorization acknowledges responsibility for any amount the physician charges.

Good to know

  • Section 2 asks for the date symptoms first appeared, the date of diagnosis and by whom, the date of the first visit and the date the patient stopped work because of the condition.
  • List investigations such as EKGs, x-rays and lab tests with the date each was carried out and a summary of results, and attach copies of all available reports.
  • The treatment section covers each medication with dosage, start date and reason for any change, other treatment providers with their specialty, and any referrals still pending or planned.
  • Co-operators' group benefits forms page lists this general statement alongside condition-specific critical illness physician statements, such as Life-Threatening Cancer and Myocardial Infarction (Heart Attack).

Get the official form

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

Critical Disease Physician Statement

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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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

Who pays for the Co-operators Critical Disease Physician Statement?

The plan member. The instructions on page 1 state that the plan member is responsible for the cost of completing this form, and the member's signed authorization in Section 1 confirms they are responsible for obtaining the form and for any amount the physician charges to complete it.

Can the patient send in the completed GL2325 themselves?

The instructions say the completed form must be emailed or faxed to Co-operators directly from the physician's office. The only other option printed is mailing the original to the Group Life Claims Department. In Section 3 you can also give an email address if you want Co-operators to contact you by email about the claim.

What should be attached to GL2325?

Section 2 asks for copies of chart notes, test results and consultation reports. The investigations table also asks you to attach copies of all available reports, such as EKGs, x-rays and lab tests, with the date each was carried out and a summary of the results.