Employees insured through Mutual of Omaha or United of Omaha use this 17-page packet to claim group short-term disability, long-term disability or both. The attending physician completes Section 5 with the diagnosis, treatment, restrictions and functional capacity, then attaches office notes from the last two years. The employee and employer complete Sections 1 through 4, and the packet goes to Mutual of Omaha's group claims team.
The attending physician completes and signs Section 5. The employee completes Section 1 and the authorization, and the employer completes Section 2, the Section 3 Job Analysis if no formal job description exists, and the Section 4 signature and attachments.
The employee answers Parts A through H: personal details and the group policy number (eight characters beginning with G000), family information used to determine Social Security eligibility, the disabling condition, work dates, care and treatment, other income benefits, tax withholding and signature. The guide defines the last day worked as the day before the first absence and the date first treated as the date the employee first sought care. Every physician and hospital that treated the condition should be listed.
The employee reads and signs this authorization, which the guide says applies for long-term disability benefits and allows disclosure of personal information to the parties processing the claim. Alternate names, such as a name change after marriage or adoption, help match medical records. The guide states the form is not complete without the employee's signature. The packet also includes an Education, Training and Work Experience page for the employee.
The employer confirms the group policy number, the dates the employee became insured under this plan and any prior plan, regular hours, and how premium is paid; if the tax part is blank, Mutual of Omaha assumes the employee paid premium with pre-tax dollars. Other parts cover life insurance waiver dates, pension plan details (not applicable to maternity) and salary, with pay method, hourly rate if applicable and supporting payroll documentation attached.
The supervisor or HR department completes the job analysis only if no formal job description exists, checking each physical activity and its frequency: occasionally means up to 33 percent of the time, frequently 34 to 66 percent and continuously 67 to 100 percent. In Section 4 the employer attaches the job description and any helpful documentation, then prints a name, title and contact details and signs.
Enter the patient's name, employer, policy number, Social Security number, height, weight, blood pressure and date of birth. For a normal pregnancy, complete Part B only: last menstrual period, expected and actual delivery dates, type of delivery, expected length of postpartum recovery and the first and last treatment dates, then go to Part E. Every date should include the month, day and year.
Give the primary diagnosis with its ICD-10 or DSM code, symptoms, diagnostic testing and objective findings, plus any contributing secondary conditions. Cardiac conditions need the American Heart Association functional capacity class or ejection fraction; psychiatric conditions need the current GAF or WHODAS score and the highest in the past year. Record symptom onset, first and last visit dates, the date the patient was first unable to work, visit frequency, work-relatedness, surgery, medications, therapy referrals, consultations and hospital confinement.
Describe restrictions (what the patient should not do) and limitations (what the patient cannot do), your prognosis, and whether maximum medical improvement has been reached; if not, estimate when fundamental changes are expected and give the treatment plan for return to work. Check full hourly capacity for sitting, standing and walking in an eight-hour day and explain any restrictions in driving, lifting, repetitive hand or foot use, bending, squatting, crawling, climbing or reaching above shoulder level.
Rate the patient's ability to adapt to job situations, such as following work rules, keeping pace, maintaining attention, handling complex instructions, relating to coworkers and supervisors and making decisions, as unlimited, somewhat limited, markedly limited or unable to perform. Then state which functions of the patient's own occupation they cannot perform with your rationale, the functional restrictions placed on them, when they should return to their prior level of functioning and whether you recommend vocational rehabilitation.
After completing the form, attach office notes for the period of treatment over the last two years, hospital discharge summaries, test results showing objective findings and consulting physician reports. Enter your name, degree, specialty, phone, fax and address, then sign and date. The signature line specifies no stamp, and a warning about filing false, incomplete or misleading statements appears just above it.
Download the current version from the source each time; forms change without notice.
Group Disability Claim Form – Section 5 Attending Physician's Statement
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Sources for this guide
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No. The Section 5 signature line reads 'Signature of Attending Physician (no stamp)', so the attending physician signs and dates it personally. The section also asks for the physician's name, degree, specialty and contact details, and carries a warning about filing false, incomplete or misleading information just above the signature.
Part E of Section 5 asks the physician, after completing the form, to attach office notes for the period of treatment over the last two years, hospital discharge summaries, test results showing objective findings and consulting physician reports. The guide adds that missing or illegible information delays processing.
Yes. Part C asks for the current GAF or WHODAS score for a psychiatric condition and the highest score in the past year. Part D rates the patient's ability to follow work rules, maintain attention, relate to coworkers and handle other job situations, from unlimited to unable to perform.
Yes. Mutual of Omaha posts a Spanish edition of the group disability claim form alongside the English January 2025 edition, footer 454126_0125. Group claim forms are listed on Mutual of Omaha's forms page after choosing the plan member (employee) option and a state.