The Standard's group accident insurance claim packet includes a two-page Attending Physician's Statement confirming the accidental injury behind a claim. The physician records the diagnosis, accident date, emergency room, urgent care and hospital treatment, CPT procedure codes and surgery, plus any loss of hearing, sight or limb or any paralysis. The Standard weighs it with the employee's statement and bills under the group certificate.
The insured or patient completes Section A, with insured and patient details, date of service and relationship to the insured, then gives the form to the attending physician. The physician completes Section B, Section C if dismemberment or impairment applies, and Section D, and signs.
The statement opens with three steps: the insured or patient completes Section A and gives the form to the attending physician; the physician completes Sections B, C (if applicable) and D; and the physician submits the signed statement and supporting documentation directly to The Standard. The physician does not need the rest of the packet, which holds the employee's statement and authorization.
The insured's name, employer, group policy number, Social Security number, date of birth, phone and mailing address come first, then the patient's name, Social Security number, date of birth, gender and date of service. The patient's relationship to the insured is marked as self, spouse, domestic partner, civil union partner or child, because the patient can be the insured or a covered family member.
Enter the diagnosis description with its code and the date of the accident or injury. Answer whether the patient was treated in an emergency room or an urgent care facility, with dates, and whether the patient was hospitalized, with admission and discharge dates. Add the CPT procedure code and description for the care you provided. The packet notes that the group policy and certificate are the ultimate authority for accident benefit decisions.
Record whether the patient has undergone surgery, with the date, procedure and result, or whether surgery is expected in the future, with date and type. Name the facility or hospital where the injury was treated, including city, state and county. Describe any other disease or infirmity affecting the patient's present condition and injuries, and attach supporting documentation.
Complete this only when the claim involves dismemberment or impairment. Answer yes or no to loss of hearing in one or both ears, loss of sight in one or both eyes, loss of limbs, and paralysis, and describe each yes answer. Attach the supporting documentation the heading asks for. The packet asks for NA in any space that does not apply, so an unused section is not mistaken for an oversight.
Give the physician's name, specialty, address, phone and fax number, then sign and date. The acknowledgement certifies that the answers are complete and true to the best of your knowledge and belief and that you have read the fraud notice that follows the statement.
Download the current version from the source each time; forms change without notice.
Accident Benefits Claim (Attending Physician's 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.
Sources for this guide
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No. The packet instructions say that for an Accidental Death Claim you do not need to have the Attending Physician's Statement completed, and no authorization is needed either. The beneficiary instead sends documents such as the death certificate, autopsy, toxicology report and accident report with the Employee's Statement, one form per beneficiary.
Section B has a diagnosis field labeled Description/ICD9, and separate fields for the procedure code (CPT) and procedure description. It also asks for the date of the accident or injury, treatment dates for emergency room or urgent care visits, admission and discharge dates, and the date, procedure and result of any surgery.
The physician does. The instructions on the statement tell the attending physician to submit the completed and signed form and supporting documentation to the address or fax number printed at the top, and the packet tells the patient that physicians should mail or fax it directly to The Standard.
Yes. The Standard's forms page lists the Accident Benefit Claim Form for all states except New York (23218) and a separate NY version (SNY 23218). Use the version that matches where the group plan was issued, since the New York company has its own contact details.