For a group disability claim based on a lung condition, Prudential asks the treating physician or pulmonologist to complete this three-page questionnaire. It covers work capacity and return date, the date pulmonary function was lost, diagnoses with ICD codes, supporting findings, labored breathing, supplemental oxygen and saturation at rest and with activity, hospitalization and ventilatory support, help with daily activities, PFT and walk test results, and workday activity limits.
The treating physician completes Section 2 and signs the certification with specialty. The claimant's name and claim number go at the top of each page.
Download the current version from the source each time; forms change without notice.
Pulmonary Capacity Questionnaire
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.
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Prudential asks for the dates and results of 6-minute walk tests and pulmonary function tests, attached to the form. If test results are not available, the physician sends a copy of the most recent office notes with exam findings instead.
The physician rates standing, walking, sitting, computer use, reaching overhead and at desk level, fingering and handling, climbing stairs, stooping and kneeling, and lifting 10, 20 and 50 pounds, each as never, occasionally, frequently or constantly during the workday.