Physician statement for a group accidental dismemberment claim.
- Completed by
- Treating physician
- Issued by
- The Co-operators
- Format
- Language
- English
Co-operators Critical Illness Physician Statements
Co-operators Life Insurance Company publishes a separate two-page physician statement for each critical illness it covers under group plans: 20 adult conditions, such as life-threatening cancer, myocardial infarction and stroke, and 8 dependent children's illnesses, such as autism and type 1 diabetes mellitus. The physician confirms the diagnosis and its key dates, and the statement goes to the Group Life Claims Department to support the critical illness claim.
Who completes it
The physician completes Section 2, Medical Information, and Section 3, Physician Information and Authorization; the cancer version specifies that the oncologist completes the medical section. The patient completes Section 1 with their name, date of birth and group, account and certificate numbers.
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 on the form.
- Who pays
- Each statement says the patient is responsible for the cost of completing the form.
Good to know
- The contract requires a covered illness to be diagnosed by a medical practitioner who is not the life insured, a relative or a business associate, and Section 3 asks you to confirm this.
- Every version asks for the date symptoms began, the date of diagnosis and the date the patient was advised of it, plus family history and any tobacco, marijuana or nicotine use.
- Questions differ by condition: the cancer statement asks for the location and staging, while the heart attack statement asks for the diagnosis with comments on severity and degree of deterioration.
- The form warns that a listed condition may not be covered under every policy and refers the patient to their group contract to confirm coverage for the condition claimed.
Get the official form
Download the current version from the source each time; forms change without notice.
Critical illness physician statements (condition-specific)
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.
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
Can a relative or colleague complete a Co-operators critical illness statement?
No. Section 3 states that the contract requires a covered illness to be diagnosed by a medical practitioner who cannot be the life insured, related to the life insured, or a business associate of the life insured. The physician must answer whether their relationship to the life insured falls into any of these three categories.
Which Co-operators critical illness physician statement should be used?
The one for the condition being claimed. Co-operators' group benefits forms page lists one statement per condition, from Alzheimer's disease or dementia to stroke, plus dependent children's statements for autism, cerebral palsy, congenital heart disease, cystic fibrosis, Down syndrome, muscular dystrophy, Rett syndrome and type 1 diabetes mellitus. A general Critical Disease Physician Statement is listed too.
What records should go with the statement?
The first medical question asks for copies of your office records, investigations performed, diagnostics, consultation reports and hospitalization summaries. A later question asks for the names and addresses of all consultants, specialists or hospitals the patient was referred to or attended for the condition, and the form asks you to print clearly and complete every section to avoid delays.