Mutual of Omaha and United of Omaha use this three-page report to collect proof of continuing loss on an open group disability claim by a return date set on the form. The employee updates work status, activities, treatment and other income on page 1. The attending physician completes page 2: whether the patient is still advised not to work, diagnosis, findings, prognosis and physical capacity.
The insured employee completes and signs page 1. The attending physician completes and signs page 2, headed To Be Completed By The Attending Physician; the signature line specifies no stamp.
Download the current version from the source each time; forms change without notice.
Supplemental Report of Disability – Proof of Continuing Loss
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.
No. The attending physician signature line on page 2 is marked no stamp, so the physician signs the statement personally and dates it. The physician also prints name, degree, specialty, phone, fax and address.
Yes. The top of the form has a return-by date filled in by Mutual of Omaha. The form is completed without expense to the company and faxed to the group claims office, with the claim number on both the employee and physician pages.