The Standard's short term disability claim packet puts the employee's statement and the Attending Physician's Statement on the same page, page 4 of 7. The physician's half documents diagnosis, pregnancy dates, treatment history, hospitalization or surgery and functional limits. The Standard says it takes about one week to decide once the completed application arrives, and it notifies the employee if it needs longer.
The employer completes the Employer's Statement on page 2 and sends it to The Standard before handing over the packet. The employee completes and signs the top of page 4, and each treating physician completes the Attending Physician's Statement below it, items 1 to 5, and signs the acknowledgement.
The top of page 4 is the employee's part: name, employer, group policy number, contact details, whether the disability is work related, last date at work and expected return date, cause of disability (accident, illness or pregnancy), work activity since the disability began, and any state disability or paid family leave filing. The employee signs it and should give you the fraud notice on page 5 with the form.
Enter the diagnosis with its ICDA classification, then the symptoms, height, weight and blood pressure. The physician section opens by saying this information is needed to document the patient's inability to work, and the employee's section names the cause of disability as accident, illness or pregnancy.
For a pregnancy claim, give the expected date of delivery and the actual date of delivery, and mark vaginal or C-section. The employee's item 3a asks for the same dates and type of delivery, so the two halves of page 4 should agree.
Give the date you recommended the patient stop work, when symptoms appeared or the accident happened, whether the patient had the same or a similar condition before, whether the condition is related to employment, and whether you completed a workers' compensation claim form. Add the first visit, visit frequency, most recent visit, planned course and duration of treatment, hospitalization dates, surgery date and type, and any surgical complications.
Describe the patient's physical and/or mental limitations and restrictions in terms of functional capacity, list factors delaying recovery if any, and say how long the limitations are expected to last: a date, unable to determine with a follow-up in a stated number of weeks, or permanently. Attach recent chart notes and pertinent records, as the section heading asks.
Type or print the name of the physician completing the form, specialty, phone, address and fax number, then sign and date the acknowledgement. Signing certifies the answers are complete and true to the best of your knowledge and confirms you have read the Claim Form Fraud Notice on page 5.
Download the current version from the source each time; forms change without notice.
Disability Insurance Employee/Attending Physician's Statement (Short Term Disability Claim Packet)
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
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes, if several physicians are treating the disabling condition. The packet instructions say each should complete a form, and the employee can request extra copies from the employer's benefits administrator. Each physician fills in the same items on page 4 (diagnosis, pregnancy if applicable, history and treatment, functional impairment and physician information) and signs separately.
The packet says that once The Standard receives the completed claim application, it takes approximately one week to make a claim decision. If no decision has been reached within one week, the employee is notified with the details. A missing or incomplete Attending Physician's Statement is part of what keeps an application from being complete.
The physician section states that the patient is responsible for obtaining a complete form without expense to The Standard. The insurer does not pay for completing it, so any charge for the statement is a matter between the practice and the patient.
Yes. The Standard's forms page lists the Short Term Disability Claim Packet for all states except New York (2047) and a separate NY packet (sny2047) for plans issued in New York. The Standard Life Insurance Company of New York is licensed only in New York and uses its own contact details on that version.