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Assurity 01-014-02255F: Disability Claim APS

Assurity Life uses this three-page Attending Physician's Statement in its individual disability income claim package. Every physician treating the claimant during the disability documents the primary diagnosis with ICD or DSM code, symptoms and objective findings, treatment, surgery and hospital stays, then describes restrictions and limitations and the expected full-time or part-time return-to-work dates.

Who completes it

Each physician who treated the claimant during the disability completes sections A to E and signs with a TIN or Social Security number. The claimant completes the Claimant Statement (01-012-02255F) and authorization, and the employer completes the Employer Statement (01-013-02255F).

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. Assurity may require proof of claim within 12 months of the loss.
Who pays
The form states that the patient is responsible for its completion without expense to Assurity Life.

Good to know

  • Section D separates restrictions (what the patient should not do) from limitations (what the patient cannot do) and asks when fundamental change is expected, from 1 to 2 months to over 6 months.
  • Section C covers pregnancy: last menstrual period, first treatment date, due date, delivery date and method, and any complications in pregnancy, delivery or postpartum.
  • Mental health claims add a class of mental impairment from Class 1 (no limitation) to Class 5 (severe), DSM axes, and whether the patient is competent to endorse checks.
  • The signature cannot be a stamp. Assurity posts separate packages for AZ, CA, IL, ME, MN, NC, NM, UT, VA and VT; this statement is revision R 10-22.

Get the official form

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

Disability 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.

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Frequently asked questions

Who completes Assurity's disability Attending Physician's Statement?

Every physician who was treating the claimant during the time of disability. The claimant lists all physicians seen in the last five years on the Claimant Statement and notes whether each provided a statement. The physician prints or types the answers, adds a sheet if needed, and signs by hand.

Who pays for the Assurity disability physician statement?

The patient. The statement says the patient is responsible for the completion of the form without expense to Assurity Life, so any charge for completing it is the patient's responsibility rather than the insurer's. The physician then returns the completed statement for submission by fax, email or mail.

Does Assurity have state-specific disability claim forms?

Yes. Besides the generic package, Assurity posts disability income claim packages for Arizona, California, Illinois, Maine, Minnesota, North Carolina, New Mexico, Utah, Virginia and Vermont. Policies issued in those states use their state version of the claim package.