After a covered diagnosis under a Pacific Life Workforce Benefits group critical illness policy, the treating physician completes this two-page statement at the end of the claim package. The physician works through the condition that applies, such as cancer, heart attack, stroke, coronary artery disease, end-stage renal failure, major organ failure or aneurysm, answers its qualifying questions, attaches the record each section names, and adds treatment, hospital and work-status details.
Section 1 identifies the primary insured and the patient. The attending physician completes Sections 2 and 3 and signs with specialty and tax ID; the insured completes the separate Insured/Patient Claim Statement.
Download the current version from the source each time; forms change without notice.
Group Critical Illness – Attending Physician Statement
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.
The physician selects invasive, non-invasive or skin cancer, adds stage details, states whether the diagnosis was made pathologically or clinically, and gives the date of biopsy or clinical diagnosis. A copy of the pathology report or clinical assessment must be included with the submission.
Yes. Section 3 asks which specific job duties the patient cannot perform, whether the physician advised the patient to stop working, the stop and return-to-work dates, and any restrictions or limitations, along with surgery, hospitalization and other treating physicians for the same condition.