Initial disability medical statement for Wawanesa Life group LTD, STD and waiver-of-premium claims.
- Completed by
- Attending physician or other medical provider
- Issued by
- Wawanesa Life
- Format
- Language
- English
Wawanesa Life Group Death Benefit Physician's Statement
Wawanesa Life accepts this one-page statement from the attending physician as proof of death for a group life insurance claim. It follows the international format for medical certification of death: the condition directly leading to death, antecedent causes ending with the underlying cause, other significant conditions and the interval between onset and death. A provincial death certificate, funeral director's statement or coroner's report can serve as proof of death instead.
Who completes it
The attending physician completes the whole statement and signs it with their address and the date. The beneficiaries complete a separate Claimant's Statement and the plan sponsor completes a Plan Sponsor Statement, as listed on Wawanesa Life's group life insurance checklist.
Submitting and payment
- How to submit it
- Return the completed form and supporting documents to Wawanesa Life's claims team; the group life checklist accepts documents by mail, email or fax, and originals are not required when sent by email or fax.
- Who pays
- The form states that the claimant is responsible for any fee for this information.
Good to know
- Enter only one cause on each of lines a, b and c; line (a) is the disease, injury or complication that caused death, not the mode of dying such as heart failure or asthenia.
- If death was due to accident, suicide or homicide, specify which and describe it briefly, and say whether an inquest was held or an autopsy performed, by whom and with what findings.
- The form asks for the dates of your first and last attendance in the last illness and whether you treated or advised the deceased during the 3 years before it.
- For accidental deaths, Wawanesa Life's group claims page says its claims team will also consider the Accidental Death Benefit if the policy includes one.
Get the official form
Download the current version from the source each time; forms change without notice.
Physician's Statement Group Life Insurance
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
Is a physician's statement required for a Wawanesa Life group life claim?
Not always. Wawanesa Life's group life insurance checklist asks for one proof of death document: a funeral director's statement or certificate, a provincial death certificate, an attending physician statement, or a medical examiner or coroner report. The insurer may request additional documents after it receives and reviews the claim.
Who pays for the Wawanesa Life physician's statement?
The claimant. The form states in capital letters that the claimant is responsible for any fee for this information. The beneficiaries complete and sign a separate Claimant's Statement, and the plan sponsor completes a Plan Sponsor Statement that includes any retained enrolment or change of beneficiary forms.
How should the causes of death be recorded?
The form says its medical certification follows the World Health Assembly recommendation of July 24, 1948, and asks you to conform to the international list of causes of death. Enter one cause each on lines a, b and c, state the underlying cause last, and give the interval between onset and death.