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 GL2647: Functional Abilities Form
Co-operators Life uses this form to build a tailored work program so plan members can remain at work or return as soon as it is medically appropriate, with accommodation. It asks only about what the member can and cannot do: physical, hand and cognitive abilities, environmental tolerances, and how long restrictions apply. The current version is GL2647, dated 06/25.
Who completes it
The treating physician or other treatment provider completes everything after the plan member information and signs with their title and licence number. The plan member's name, group account, certificate and occupation appear at the top.
Submitting and payment
- How to submit it
- Send the completed form to Co-operators' Disability Claims Department by email or fax, or mail the original, using the contacts printed at the top of the form.
- Who pays
- Co-operators reimburses the member for professional fees for this form up to the amount the provincial medical association suggests for this type of service, so give the patient a paid-in-full receipt.
Good to know
- Do not include diagnostic or treatment information, including medication; the form asks only about functional abilities and restrictions.
- Physical tasks are rated by hours per workday: full (8 hours), frequent (up to 5.5), occasional (up to 2.5), seldom (up to 30 minutes) or restricted.
- Lifting and pushing or pulling limits are given for each side in bands from 0 to 20 lbs up to 51 to 100 lbs, with a five-level hand strength scale.
- You state whether the member can do the job fully, within the listed abilities, or not at all, plus a reassessment date and full or graduated hours.
Get the official form
Download the current version from the source each time; forms change without notice.
Functional Abilities
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
Does the Co-operators Functional Abilities form need a diagnosis?
No. The form asks providers not to include any diagnostic or treatment information, including medication. It asks whether the condition is work-related, whether a treatment plan exists, and whether current treatment or medication could impede the member's safe performance of their job.
Who pays for the Co-operators Functional Abilities form?
The member pays the provider, then Co-operators reimburses the member for professional fees for this form, as long as they do not exceed the amount suggested by the provincial medical association for this type of service. The form asks providers to give the patient a paid-in-full receipt.
What cognitive abilities does GL2647 rate?
Alertness, concentration, memory, judgement, multiple tasks, critical decision-making, problem solving with speed and accuracy, interpersonal contact and operating motorized equipment. It also rates tolerance for heat or cold, dust, fumes or odours, and chemicals, each on the same scale from full abilities to restricted.