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 GL2323: Dismemberment Physician Statement
Co-operators Life Insurance Company requires this two-page statement from the treating physician when a plan member claims a group dismemberment benefit after an accident or disease. It documents the diagnosis, the injury and the type of loss claimed: amputation, total loss of use or paralysis, or loss of vision, speech or hearing. A body diagram on the form lets you mark the loss and the level of amputation.
Who completes it
The physician providing treatment completes Section 2, Medical Information, and signs Section 3 with their certified specialty and stamp. The plan member completes Section 1 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 on the form.
- Who pays
- The plan member is responsible for the cost of completing this form.
Good to know
- For loss of use, the form asks whether the accident or disease caused total and irrecoverable loss of use or paralysis, and whether it has been continuous for 12 months.
- For vision, speech or hearing, give the percentage of loss and say whether a device or rehabilitative program could restore it; for sight, record vision in each eye before and now.
- Question 6 asks whether the accident or disease was solely responsible for the loss and, if not, for details of any contributing causes.
- Attach chart notes, test results and consultation reports. Co-operators' forms page lists a separate Dismemberment Statement next to this physician statement.
Get the official form
Download the current version from the source each time; forms change without notice.
Dismemberment Physician Statement
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.
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Frequently asked questions
What does the Co-operators dismemberment form ask about amputation?
Question 3 asks which part was lost (hand, foot, arm, leg or finger), the date of amputation and whether amputation was necessary as a result of the accident or disease. The form includes a body diagram so you can indicate the loss and the level of amputation.
Who pays for the Dismemberment Physician Statement?
The plan member. The instructions state that the plan member is responsible for the cost of completing the form, and the member's signed authorization in Section 1 acknowledges responsibility for obtaining the form and for any amount the physician charges to complete it.
How is GL2323 returned to Co-operators?
The instructions require the completed form to be emailed or faxed to Co-operators directly from the physician's office, or the original mailed to the Group Life Claims Department. If you want Co-operators to contact you by email about the claim, you can provide an email address in Section 3.