Sun Life uses this statement to get the attending physician's account of a group long-term disability claim, which employees file when a disability extends beyond the elimination period in the employer's policy. It covers diagnoses with ICD-10 codes, pregnancy complications, diagnostic tests, treatment, a workday activity grid, hand use, any mental impairment and return-to-work timing.
The attending physician completes each section, 1 through 7, then signs and dates it. The employee files Sun Life's separate LTD employee statement (GLTDFM-11120) with medical authorizations, and the employer completes the employer statement (GLTDFM-11119).
Enter the group policy number, the patient's name and sex, address, Social Security number, date of birth, phone and the employer's parent company name. This section also states that the patient is responsible for any costs of completing the form. Each page also has a strip for the claimant name, date of birth, policy number and CC number.
Give the primary diagnosis, including any complications, and any secondary diagnosis, each with an ICD-10 code. Answer whether the patient ever had the same or a similar condition and when. For a pregnancy, give the expected due date, actual delivery date and delivery type, and list complications that caused the patient to stop work early or that would extend normal recovery.
Mark whether the injury or sickness is work related (yes, no or unknown). The diagnostic testing table has rows for X-ray, EKG, MRI, PFT, ultrasound and other, each with the test date and findings. Sun Life's instructions stress answering as completely as possible, because follow-up requests can delay the patient's benefits.
Enter the start date of disability and the dates of the first, last and next office visits. Answer whether emergency room care was required, with the hospital and date. Check and describe each type of treatment that applies: surgery, medications prescribed, therapy, behavioral intervention or other, with frequency and dates. Mark whether the patient is hospital confined, house confined, bed confined or ambulatory, with dates.
Describe what the patient is unable to do (limitations) and what the patient should not do (restrictions), each with From and To dates. Then answer whether the patient can work with these restrictions, full-time or part-time with hours per day, and how long a part-time schedule would last. The section also asks whether the patient is competent to endorse checks and manage financial affairs.
Mark the dominant hand and, for each hand, whether the patient can do simple grasping, firm grasping, fine manipulation and keyboarding. Complete the typical-workday grid, including weights for lifting and carrying. If cardiac, choose the American Heart Association functional class. Estimate how long the limitations will apply (6 to 8, 8 to 12 or 12 to 26 weeks, or a recovery date), and for mental impairment give the current DSM diagnosis and Class 1 to 5.
For both the patient's part-time occupation and full-time occupation, give a specific date or pick a recovery period: 1 to 2 weeks through 7 to 8 weeks, 2 months or more, never, or other. Sun Life asks for the date or period after which the patient will be able to sufficiently perform duties; choose Never or Other where neither fits.
List other treating physicians with specialty, phone and fax, and check the box and attach a separate sheet if you need more room. Then enter your name, tax ID number, address, specialty, phone and fax, and sign and date. Signing certifies the statements are true and complete and that you have read, or had read to you, the fraud warning for your state.
Download the current version from the source each time; forms change without notice.
Long-Term Disability Claim Statement – Attending Physician
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.
Sources for this guide
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When the patient files a group long-term disability claim with Sun Life. The employee claim instructions say to submit an LTD claim if the disability extends beyond the elimination period in the employer's group policy. The physician statement documents the medical side, while the employee and employer statements cover the job, earnings and coverage details.
No. The grid asks how often in a typical workday the patient can walk, sit, stand, bend, squat, climb, twist, push, pull, balance, kneel, crawl, reach above shoulder, lift, carry, drive and use foot pedals. The form states plainly that this is not considered an FCE. Each activity is rated continuously, frequently, occasionally or negligible.
Section 1 of the form states that the patient is responsible for any costs associated with the completion of this form. Sun Life does not pay the physician for it, so any charge is set by the practice and billed to the patient.
GLTDFM-11121 is the initial attending physician statement for a new LTD claim. The Long-Term Disability Medical Update, GLTDFM-11245, is a shorter follow-up form asking for the last and next exam dates, current diagnosis and symptoms, full-time or part-time work capacity, and restrictions. If you are unable to complete the update, it asks for copies of records, exam findings, test results and the current treatment plan instead.