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Assurity 01-098-02241F: Critical Illness Claim APS

Assurity Life uses this Attending Physician's Statement to decide critical illness claims. The physician completes General Information (diagnosis, when symptoms began, prior treatment for a similar condition) and only the section for the illness claimed, such as cancer, heart attack, stroke, kidney failure, organ transplant or advanced Alzheimer's disease, answering the policy criteria and giving the qualifying date.

Who completes it

All physicians who treated the claimant complete General Information and the section for the claimed illness, then sign with degree, specialty and TIN or Social Security number. The claimant completes the Claimant Statement (01-097-02241F) and the Confidential Information Authorization (40-500-05055).

Submitting and payment

How to submit it
The claimant prints the statement for the physician, and the completed form goes to Assurity by fax, email or mail. Claims for a spouse or a child 18 or older must be submitted that way rather than online.
Who pays
The form states that the patient is responsible for its completion without expense to Assurity Life.

Good to know

  • Heart attack claims need yes or no answers on clinical symptoms, rise and fall of cardiac markers, new ECG changes and heart muscle death, plus the date all criteria were met.
  • Advanced Alzheimer's disease needs cognitive and neuroradiological testing and help with at least three of six ADLs; Loss of Independent Living needs permanent inability to perform two or more.
  • Pathology reports, physician notes, medical records and itemized bills can be sent with the claim to speed it up. For other covered conditions, attach copies of the diagnostic testing.
  • The signature cannot be a stamp. State packages exist for AZ, CA, IL, ME, MN, NC, NM, UT, VA and VT; this statement is revision R. 11.17.24.

Get the official form

Download the current version from the source each time; forms change without notice.

Critical Illness Claim Attending Physician's Statement

Official pagePDF

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 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.

Frequently asked questions

Which sections of the Assurity critical illness APS does the physician complete?

General Information plus the section for the critical illness being claimed. Sections cover cancer, heart attack, angioplasty, coronary bypass, sudden cardiac arrest, stroke, TIA, kidney failure, major organ transplant, advanced Alzheimer's disease, loss of independent living and other covered conditions. Sections for illnesses not claimed are left blank.

Does an Assurity critical illness cancer claim need a pathology report?

If the cancer was diagnosed pathologically, yes: attach a copy of the pathology report. If it was diagnosed clinically, the physician explains why a pathological diagnosis was not obtained and attaches evidence supporting the diagnosis. The cancer section also asks for the stage and the date the specimen was taken.

Who pays for the Assurity critical illness physician statement?

The patient. The statement says the patient is responsible for the completion of the form without expense to Assurity Life. It is requested from every physician who treated the claimant, and the claimant sends the completed statements to Assurity by fax, email or mail.