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Lincoln DP 402D: Liberty Life Disability APS (Part B)

Lincoln Financial Group uses this statement for group disability claims on legacy Liberty Life Assurance Company of Boston policies, a business Lincoln acquired in 2018. The employee completes Part A and the attending physician completes Part B: diagnosis, symptom onset, date advised to stop work, treatment plan and medications, impairment classes and estimated return to work.

Who completes it

The employee completes Part A, the authorization. The attending physician completes Part B, including physical, mental and cardiac impairment classes, and signs with degree, specialty and tax ID.

Submitting and payment

How to submit it
Return the statement to Lincoln Financial Group's group disability claims unit with the original claim, or by the date Lincoln requests, using the contact details printed on the form.
Who pays
The form states it is to be completed without expense to Lincoln Financial Group.

Good to know

  • Attach office notes for the treatment period or the last two years, test results showing objective findings, any hospital discharge summary and consulting physicians' reports.
  • Physical impairment uses five classes, from Class 1 (no limitation, capable of heavy work) to Class 5 (severe limitation, incapable of minimum activity).
  • Mental or nervous impairment uses a matching five-class scale, and cardiac impairment uses American Heart Association functional classes with the last blood pressure.
  • The footer reads DP 402D Rev 12/18. It travels in a combined packet with the employee's DP 477D claim form and the employer's statement.

Get the official form

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

Attending Physician's Statement (Liberty Life group disability claim, Part B)

Official pagePDF

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Frequently asked questions

Is Liberty Life DP 402D still used after Lincoln's acquisition?

Yes. Lincoln acquired Liberty Mutual's group benefits business in 2018, and Liberty-series DP forms remain in use for those policies. The DP 402D statement names Liberty Life Assurance Company of Boston, a Lincoln Financial Group company, and goes to Lincoln's group disability claims unit.

What records go with the DP 402D statement?

Item 9 asks the physician to attach office notes for the period of treatment or the last two years, test results showing objective findings, the hospital discharge summary if applicable, and consulting physicians' reports if applicable.