Disability, critical illness, accident, hospital, life and long-term care claim forms from national carriers, each with a section the treating clinician completes.
Insurers ask the treating clinician to document disability, critical illness, accident, hospital and life claims on an attending physician statement (APS). Common examples are Unum's Short Term Disability Claim Form (CL-1104), Aflac Group's critical illness and disability claim forms, and Colonial Life's Disability Claim (64387), Critical Illness Claim (65017) and Accident Claim (67715). Carriers also send condition-specific questionnaires, from Prudential's cardiac, cancer and pulmonary statements to behavioral health statements from Guardian, Sun Life and Prudential.
Most are fillable PDFs, and the claimant and employer complete their own sections. Who pays varies: Guardian's LTD statement and The Hartford's APS put the cost on the patient, while Aflac's life waiver asks the physician to complete it without expense to the insurer. The Hartford and Lincoln Financial send forms per claim. 14 forms here have a Spanish version. Vero Documents fills these PDFs from the visit note and the chart, and any fillable PDF you upload becomes a template the whole clinic can use.
Attending physician confirms how and when a covered critical illness was diagnosed (pathologically/clinically) for an Aflac Group critical illness claim.
Physician certifies the disability, diagnosis and expected return-to-work date for an Aflac Group supplemental short-term disability claim.
Attending physician documents the cancer diagnosis and treatment for an Aflac Group cancer insurance claim.
Physician assessing return to work updates an open Aflac Group supplemental disability claim.
Attending physician certifies terminal illness or ADL impairment so an Aflac Group life insured can receive an accelerated death benefit.
Treating physician certifies the employee's disability so Aflac Group life insurance premiums are waived.
Certifying physician documents ADL dependence or cognitive impairment so the long-term care benefit of an Aflac Group term-to-120 life policy is paid.
Primary care physician certifies a terminal illness (life expectancy of 12 months or less) so an American Income Life policy pays an accelerated death benefit.
01-014-02255FEach physician treating the claimant at the time of disability documents diagnosis, treatment and restrictions for an Assurity individual disability income claim.
Treating physician completes the general information and the section for the claimed critical illness so Assurity can pay a critical illness benefit.
ACC-CLM-CIPhysician documents the accidental injury, diagnosis, treatment and any time unable to work for a Combined Insurance accident policy claim.
DI-CLM-CIPhysician documents the diagnosis, period of disability and restrictions for a Combined Insurance sickness/short-term disability income policy claim.
CI-CLM-CIPhysician confirms the diagnosis and date of diagnosis of a covered critical illness for a Combined Insurance critical illness claim.
64387-28Documents the diagnosis, restrictions and expected return-to-work date so Colonial Life can pay a short-term disability (income replacement) claim.
65017-26Physician confirms the date and basis of diagnosis of a covered critical illness (e.g., heart attack, stroke, cancer) for a lump-sum critical illness benefit.
67715-26Physician confirms the accidental injury, diagnosis and treatment dates so Colonial Life can pay accident-policy benefits.
Physician or facility confirms admission/discharge dates, diagnosis and procedures for Colonial Life hospital indemnity and outpatient surgery benefits.
08727-70Multi-policy Colonial Life claim covering accident, hospital confinement, surgery and sickness benefits with one physician statement.
46988-35Physician update on an open Colonial Life disability claim confirming the patient remains unable to work and the new estimated return date.
49507-37Obstetric provider confirms delivery date, type of delivery and complications for Colonial Life pregnancy/maternity benefits.
74273-22Physician documents a cancer diagnosis (pathology, staging, treatment) for Colonial Life cancer insurance benefits.
57930-24Physician certifies a catastrophic loss (paralysis, loss of limbs, sight, hearing, etc.) from an accident for a Colonial Life catastrophic accident benefit.
Treating physician documents the accidental injury and treatment for a Family Heritage accident policy claim.
Treating physician documents cancer diagnosis, treatment or ICU confinement on side 2 of a Family Heritage cancer or intensive care claim.
Physician's office confirms the date and basis of a first cancer diagnosis for Family Heritage's first-occurrence lump-sum benefit.
The deceased's medical provider reports cause of death and treatment history for a Family Heritage life insurance death claim.
Treating physician states the reason for and dates of hospital confinement for a Family Heritage hospital indemnity claim.
Treating physician documents a heart attack, stroke or related treatment for a Family Heritage heart and stroke policy claim.
Claims FEGLI accidental dismemberment benefits for loss of a limb or eyesight; the provider documents the accident, loss and dates.
Lets a terminally ill FEGLI enrollee (life expectancy of 9 months or less) receive Basic life insurance as a living benefit; a physician must certify the terminal illness.
Attending physician documents diagnosis, pregnancy/delivery details, treatment, restrictions and expected return to work for a Guardian group short term disability claim.
GG-016415Attending physician section of Guardian's group LTD claim packet: diagnosis, functional status (e.g. house or hospital confined), treatment and prognosis.
Treating provider updates treatment plan, compliance, expected recovery and hour-by-hour functional capacity for an ongoing Guardian LTD claim.
GG-016453Treating physician documents cancer diagnosis, staging and treatment/hospital services for a Guardian group cancer insurance claim.
Attending physician certifies disability from an accidental injury for the disability rider of a Guardian group accident policy.
GG-018097Behavioral health provider rates the patient's neurocognitive, interpersonal and persistence capabilities (0-3 scale) for a disability claim based on a mental health condition.
Physician updates the patient's progress, release to return to work and restrictions for an open Guardian STD claim.
Provider states whether the LTD claimant is mentally competent to manage benefit payments and since what date.
Treating provider documents the immunocompromising condition, treatment and work restrictions for an LTD claim.
Physician statement supporting waiver of group life premiums for a totally disabled insured.
GG-011711Physician certifies terminal illness diagnosis and life expectancy for a group life accelerated benefit.
Attending physician confirms a dismemberment, coma or paralysis from an accident for a Guardian individual (direct-to-consumer) accident policy claim.
GG-016981-LIFETreating clinician documents behavioral health diagnosis, treatment plan and vocational prognosis for a Guardian group life waiver-of-premium claim.
Physician scores the patient's post-stroke disability on the Modified Rankin Scale to support a Guardian group critical illness (stroke) claim.
GG-017704-STDCondition-specific questionnaire in which the treating provider documents lupus criteria, ADL impact, medications and restrictions for an STD claim.
NJTDBDS1Claim for New Jersey temporary disability benefits under an employer's Guardian private plan, including the physician's certification.
GLC-01450ATLAttending physician documents onset, diagnosis, treatment, ambulatory/confinement status and the date the patient became unable to work for a Lincoln group long term disability claim.
Attending physician section of the legacy Liberty Mutual group disability claim form: diagnosis, symptom onset, date advised to cease work, treatment plan, medications and estimated return to work.
Physician statement of symptom onset, date the patient stopped work, diagnosis and expected return for a Lincoln group short term disability claim.
APS-STD-LTD-5320Physician documents diagnosis, pregnancy/delivery details, findings, treatment and hour-by-hour physical capacities so MetLife can decide or continue a group STD or LTD claim.
Claim for New Jersey temporary disability benefits under an employer's MetLife-insured private plan; physician certifies the sickness/injury and disability dates.
Combined STD/LTD claim packet whose Section 5 the attending physician completes with diagnosis, dates, treatment and restrictions.
Standalone STD claim packet; the attending physician completes Section 3 so the claim is considered complete.
Attending physician confirms the diagnosed illness/procedure and dates for a Mutual of Omaha group (worksite) critical illness/specified disease claim.
Employee and attending physician update an open disability claim; the physician states whether the patient is still advised not to work and current restrictions.
Treating physician documents history, diagnosis, treatment dates, return-to-work status and limitations for a Mutual of Omaha individual disability income claim.
Attending physician certifies a terminal condition so a group life insured can receive an accelerated (living) death benefit.
Physician reports a deceased insured's disability (with ADLs) before death to establish group life benefits continued under a disability provision.
Attending physician statement supporting a group life waiver-of-premium claim for a disabled employee.
Physician certifies an over-age dependent's diagnosis and incapacity so group coverage can continue.
Attending physician documents diagnoses, cognitive status and ADL dependence so Mutual of Omaha can decide eligibility for long-term care insurance benefits.
M20410Periodic update on a continuing Mutual of Omaha individual disability claim; the physician's supplementary statement confirms ongoing disability and treatment.
Treating physician documents history, diagnosis, functional and mental capacity limitations for a new New York Life individual disability insurance claim.
Treating physician updates diagnosis, treatment and restrictions for an ongoing New York Life individual disability claim.
Treating mental health clinician documents psychiatric diagnosis, mental status and capacity limitations for a New York Life individual disability claim.
Treating physician documents diagnosis, treatment, medications and 8-hour-workday physical limitations for a group short- or long-term disability claim with NYL GBS (formerly Cigna group disability).
Health care provider documents the impairment or pregnancy-related limitation and the workplace accommodation needed for an ADA/PWFA accommodation request administered by NYL GBS.
Physician answers targeted questions on the impairment, restrictions and whether the patient could return to work with accommodations.
Treating physician documents the accidental injury, diagnosis and treatment for a Pacific Life group accident insurance claim.
Treating physician confirms hospital admission/confinement dates and diagnosis for a Pacific Life group hospital indemnity claim.
Physician documents the diagnosis and supporting findings (e.g., troponin for heart attack) for a Pacific Life group critical illness claim.
Treating physician certifies total disability (diagnosis, confinement, functional capacity) so group life premiums are waived.
Attending physician certifies a terminal illness with life expectancy under 12 months so a Pacific Life group life insured can receive an accelerated death benefit.
Doctor's statement supporting a Principal group disability claim for sickness, injury, pregnancy or a mental health condition.
Attending physician documents diagnosis, treatment, other treating providers and functional abilities for a Prudential group STD/LTD claim.
Behavioral health clinician documents DSM diagnoses, rationale for disability leave, mental status and treatment goals for a group disability claim.
GL.2012.240Physician grades current physical capacities (never/occasional/frequent/constant), part-time capacity and full-time return-to-work estimate.
GL.2015.155Employee's health care or rehabilitation provider documents impairments, limitations and suggested workplace accommodations for an ADA accommodation request administered by Prudential.
GL.2019.254Oncology-specific questions (stage, treatment, side effects, prognosis) for a cancer-related disability claim.
GL.2020.025Follow-up physician statement with ICD codes, pregnancy EDC/delivery date, date of significant loss of function and current restrictions for an open disability claim.
GL.2022.201Health care provider records restrictions and limitations at each office visit so the employer can review return-to-work or modified duty.
GL.2025.117Behavioral health provider rates the claimant's cognitive and social work capacities and psychosocial stressors for a disability claim.
GL.2009.345Eye care physician records best-corrected acuity, visual fields and visual work limitations for a vision-related disability claim.
GL.2012.239Neurologist documents MS diagnosis history, course and latest neurological exam for a disability claim.
GL.2015.038Physician assesses whether a claimant with a psychiatric condition is ready to return to work, with standardized tests or corroborating information.
GL.2016.027Attending physician scores Kurtzke functional systems for an MS patient claiming group life waiver of premium.
GL.2019.255Cardiology-specific questions (functional class, testing, medications, restrictions) for a cardiac disability claim.
GL.2021.170Physician documents pulmonary testing, ADL assistance and exertional limits for a respiratory disability claim.
Behavioral health treating provider documents DSM diagnosis, mental status exam, treatment and functional limitations for an STD or LTD claim based on a mental health condition.
Attending physician documents diagnosis and history, pregnancy complications, restrictions/limitations and return-to-work information for a group long-term disability claim.
Attending physician documents diagnosis, restrictions/limitations and return-to-work timing so Sun Life can decide a group short-term disability claim.
GDIFM-11252Behavioral health provider updates diagnosis, treatment, restrictions and competency for an ongoing disability claim.
GLTDFM-11245Treating provider updates current findings, restrictions and limitations for an ongoing long-term disability claim.
GSTDFM-5144Treating provider answers questions on the claimant's psychiatric condition, DSM diagnosis, treatment and return-to-work goal for an STD claim.
Treating provider updates the claimant's psychiatric condition, medications and return-to-work goal for an open STD claim.
Physician certifies that an unmarried dependent child is incapable of self-sustaining employment due to mental or physical handicap so group coverage can continue past the age limit.
Attending physician statement for group life waiver of premium (total disability) and accelerated (terminal illness) benefits.
Attending physician statement for Sun Life's voluntary 'Customized Disability' (worksite) income product.
Provider documents the disabling diagnosis, onset, pregnancy delivery date, treatment and level of functionality for a new group STD/LTD or leave claim.
Provider updates current disabling diagnoses (ICD-10), projected full-time return-to-work date and level of functionality for an open group disability claim.
SI 2047Combined employee and attending physician statement used to file a group short term disability claim with The Standard.
Attending physician documents diagnosis, hospitalization, assessment of physical/mental limitations and prognosis for a group long term disability claim.
Physician documents the accidental injury, diagnosis and treatment dates for a Standard group/voluntary accident insurance claim.
Treating physician documents diagnosis, restrictions and limitations, and prognosis for a claim under The Standard's individual disability income insurance policy.
Physician confirms the condition, diagnosis date and supporting tests for a Standard critical illness benefit claim.
Physician confirms the hospital admission, diagnosis and treatment for a Standard hospital indemnity benefit claim.
Physician statements (diagnosis plus a physical capacities assessment) supporting waiver of group life insurance premiums for a totally disabled member.
Physician documents the patient's inability to work for a New Jersey temporary disability claim under an employer's private plan insured by The Standard.
A112-2497Physician confirms a critical illness or cancer diagnosis for a Trustmark critical illness and cancer policy claim.
Attending physician documents diagnosis, treatment and functional capacity so Trustmark can pay a worksite (voluntary) disability income claim.
Obstetric provider documents delivery date/type and disability period for a Trustmark voluntary disability pregnancy claim.
Physician confirms diagnosis and dates of a covered critical health event for a Trustmark Critical HealthEvents claim.
Physician primarily responsible for care documents ADL/cognitive impairment and treatment so Trustmark can pay the long-term care/home health care benefit on its universal life (LifeEvents / Life + Care) policies.
Attending physician certifies the insured's disability so premiums on a Trustmark life policy are waived.
Attending physician certifies a terminal illness so a Trustmark life policy pays an early (accelerated) death benefit.
Physician updates a continuing Trustmark voluntary disability claim with current treatment, restrictions and expected return-to-work date.
Documents diagnosis, pregnancy dates, treatment, restrictions/limitations and expected return-to-work date so Unum can decide a group short term disability claim.
Physician confirms diagnosis date and basis for a Unum voluntary benefits critical illness/specified disease and/or cancer claim.
Documents diagnosis, functional capacity (restrictions and limitations) and other treating providers so Unum can decide a group long term disability (and life waiver of premium / IDI) claim.
CL-1023Physician confirms the accidental injury, diagnosis and treatment for a Unum supplemental health accident insurance claim.
Treating physician documents diagnosis, functional restrictions and prognosis for a Unum individual disability income (IDI) policy claim.
Periodic update of the claimant's condition and functional capacity used to evaluate continued eligibility for group disability benefits.
Physician statement supporting a worksite (voluntary benefits) disability income claim: pregnancy or illness details, treatment, restrictions and return-to-work assessment.
CL-1161Physician or facility confirms admission/discharge dates, diagnosis and procedures for a Unum supplemental hospital indemnity claim.
Physician confirms diagnosis of a covered critical illness/specified disease or cancer for a Unum group critical illness claim.
Eye care provider requests coverage of medically necessary (non-elective) contact lenses under a Unum group vision plan.
Attending physician statement supporting a request to waive group life premiums because the employee is totally disabled.
Physician statement for an LTD spouse-disability benefit, including cognitive impairment and ADL questions.
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 and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Usually the patient, when the form says anything. Guardian's LTD statement and The Hartford's Attending Physician's Statement say the patient is responsible for the cost, Mutual of Omaha's incapacitated dependent form puts any fee on the employee, and Unum's voluntary benefits disability form says Unum is not responsible for completion expenses. Lincoln Financial's disability statement and Aflac Group's life waiver form ask to be completed without expense to the company.
The CL-1104 is Unum's Short Term Disability Claim Form. The attending physician or treating provider documents the diagnosis, pregnancy dates, treatment, restrictions and limitations, and the expected return-to-work date; the employee and employer complete their own statements. It is an 11-page fillable packet, with a bilingual English and Spanish version, CL-1104-BL. Long term disability claims use the CL-1019, which also covers life waiver of premium.
To confirm the covered illness and the date and basis of diagnosis, sometimes with supporting findings such as troponin for a heart attack. Examples include Aflac Group's Critical Illness Claim Form, Colonial Life's 65017, Unum's CL-1198, Pacific Life's WB-132 and Combined Insurance's CI-CLM-CI. For stroke claims under its group critical illness plan, Guardian adds a Modified Rankin Scale form that the attending physician scores.
A physician statement certifying that the insured is totally disabled, so the insurer waives life insurance premiums. Guardian (GG-117), The Standard (SI 1284), Trustmark (A112-2512_APS), Unum (CL-1234), Mutual of Omaha (465891) and Pacific Life each publish one. The Standard's packet adds a physical capacities assessment, and Prudential has a Kurtzke Functional Systems Scores form for MS patients claiming waiver of premium.