When a group life claim depends on benefits continued under a disability provision, Mutual of Omaha asks the deceased's attending physician for this report. The physician states when the disability began, its diagnosis and findings, which activities of daily living needed assistance and from when, and whether total disability continued without interruption until death.
The deceased's attending physician completes and signs the whole form, including whether they were related to the deceased and how long they knew the deceased.
Download the current version from the source each time; forms change without notice.
Report of Deceased's Disability Prior to Death – Attending Physician's Statement
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Group life benefits can continue under a disability provision. This report helps Mutual of Omaha establish whether the insured was disabled before death and whether that disability continued without interruption from its start until death, which the group life claim relies on.
Form 465890 includes the activities of daily living section. Mutual of Omaha also lists a version without ADL questions, form 465889. Both are attending physician's statements reporting the deceased's disability before death, and Spanish versions are listed.