Sun Life uses GLFM-7793 for the medical side of several group life benefits: waiver of premium for a totally disabled insured, accelerated benefits for terminal illness or qualifying events, accidental dismemberment, and permanent total disability. The physician documents diagnosis, life expectancy band, qualifying events, treatment, progress, functional limits and work capability, and a separate behavioral health statement covers psychiatric claims.
The attending physician completes, signs and dates the statement, including the claim and patient information sections. For behavioral health conditions, the physician completes the separate behavioral health statement in the same form.
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Life Disability Benefits Claim Statement – Attending Physician
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The form lists four uses: waiver of premium when the insured is totally disabled, accelerated benefits for terminal illness and qualifying events, accidental dismemberment benefits for accidental bodily injury or loss, and permanent total disability benefits. The physician completes it once they can assess eligibility.
It asks for a mental impairment level from no limitation to severe, a current DSM diagnosis, when psychiatric symptoms began, any hospitalization or intensive or partial programs, chemical dependency, psychological testing, treatment plan, medications, response to treatment, functional limits and whether the patient can endorse checks.