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 GL1601: Proof of Death Physician Statement
Co-operators Life Insurance Company asks the deceased's attending physician for this statement to prove death on a group life insurance claim. It records the date and place of death, the immediate and underlying causes with the interval between onset and death, and whether an inquest or autopsy took place. The forms page lists it with the Notice of Death statements completed by the claimant and the plan sponsor.
Who completes it
The attending physician completes the deceased's information and cause-of-death questions in Section 1 and signs the acknowledgement in Section 2 with their certified specialty and stamp. The claimant and the plan sponsor each complete a separate Notice of Death statement.
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 form states that the claimant is responsible for the cost of completing it.
Good to know
- If the death was not solely the result of an illness or disease, the form asks you to describe the circumstances, for example an accident or suicide.
- You are asked how long you treated the deceased and to list any other physician, hospital or institution that treated them during the last 3 years, with the nature of the illness and dates.
- The form also asks whether the deceased was advised of the nature of their illness and when, and whether they ever used tobacco, marijuana or nicotine products.
- Section 2 is a declaration that the answers are accurate and complete; you can add an email address if you want Co-operators to communicate with you about the claim by email.
Get the official form
Download the current version from the source each time; forms change without notice.
Proof of Death Physician's 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
Who pays for the Co-operators Proof of Death Physician Statement?
The claimant. The instructions on page 1 of GL1601 state that the claimant is responsible for the cost of completing this form. The completed statement 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.
What does GL1601 ask about the cause of death?
It asks for the immediate cause of death, underlying causes and other significant conditions, each with the interval between onset and death. If the death was not solely the result of illness or disease, you describe the circumstances, and you state whether an inquest was held or an autopsy performed, and by whom.