When an employee claims group critical illness benefits from The Standard, the treating physician confirms the covered condition on the packet's Attending Physician's Statement. Section B lists covered illnesses, from cancer, stroke and heart attack to childhood conditions such as cystic fibrosis or tetralogy of Fallot, and asks for the primary diagnosis, diagnosis date, first symptoms, first consultation and any hospitalization.
The insured or patient completes Section A and gives the form to the physician. The attending physician completes Sections B and C; the employee separately completes the Employee's Statement and authorization.
Download the current version from the source each time; forms change without notice.
Critical Illness 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.
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Adult conditions include advanced Alzheimer's, ALS, benign brain tumor, cancer, carcinoma in situ, coma, coronary artery bypass, end-stage renal failure, loss of sight, hearing or speech, major organ failure, myocardial infarction, paralysis and stroke. A child disease column lists congenital conditions such as cleft palate and spina bifida.
No. The Standard uses SI 23226 in all states except New York and Vermont. Those states use the Specified Disease Benefit Claim Form, SNY 23226 for New York and 23226VT for Vermont, each with its own physician section.