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 GL2554-LTD: Mental Health LTD APS
Co-operators Life uses this four-page statement for group long-term disability claims when the primary diagnosis is a mental health condition. A Disability Case Manager reviews it with the job description to decide whether the member meets the policy's definition of total disability, and Co-operators then reviews rehabilitation potential. The current version is GL2554-LTD, dated 09/24.
Who completes it
The plan member signs an authorization releasing medical information to the plan administrator, plan adjudicator and insurer. The physician providing treatment completes the Medical Information section and signs the acknowledgement on the last page.
Submitting and payment
- How to submit it
- Return it to Co-operators Life Insurance Company's Disability Claims Department by mail, fax or email, as listed on the form.
- Who pays
- Co-operators states on the form that the plan member pays the cost of completing it.
Good to know
- If the condition is chronic, the form asks what precipitated the absence from work, along with the date the patient ceased work because of the current condition.
- It asks whether the condition relates to an occupational illness or injury, an auto accident or a criminal act, and whether the diagnosis has been communicated to the patient.
- Co-operators' employer guide asks for claims four to six weeks before the end of the elimination period, alongside the employer's long-term disability plan sponsor statement.
- Participation in rehabilitation programming recommended by Co-operators' Rehabilitation Case Managers is a requirement of its policies, according to its employer guide.
Get the official form
Download the current version from the source each time; forms change without notice.
Long Term Disability – Attending Physician’s Statement for Mental Health Conditions
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 return-to-work questions are on the Co-operators LTD mental health statement?
The prognosis section asks for the prognosis for recovery with timelines, the return-to-work goals you have discussed with the patient, and the circumstances under which they could return, such as modified duties, a gradual return to work or an alternate employer.
How does Co-operators approach return to work on long-term disability?
Its employer guide ranks goals in order: the same occupation with the same employer, a different occupation with the same employer, the same occupation with a different employer, then a different occupation with a different employer. Rehabilitation Case Managers plan returns and may facilitate treatment and vocational help.
Is the LTD statement different from the STD mental health statement?
The questions are the same in GL2554-LTD and GL2554-STD; only the title and form code differ. Use the one that matches the benefit being claimed, so it travels with the matching plan sponsor statement for long-term or short-term disability.