Trustmark uses this 3-page Attending Physician Statement when an insured applies to have life insurance premiums waived because of disability. The physician documents history, diagnosis with subjective and objective findings, treatment dates and medications. The form then grades physical and mental or nervous impairment on 5-class scales and asks whether the patient is totally disabled from their own job and from any other work.
The attending physician completes all nine items and signs page 3. The insured files the separate Begin Waiver of Premium claim form, A112-2512, posted with this statement on Trustmark's Voluntary Benefits forms page.
Download the current version from the source each time; forms change without notice.
Application for Waiver of Premium – Attending Physician Statement
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Physical impairment is graded Class 1 (no limitation) through Class 5 (severe limitation), with Class 2 light manual activity and Class 3 sedentary work. A separate mental or nervous scale runs from Class 1, able to function under stress, to Class 5, significant loss of psychological and social adjustment.
Yes. It asks whether you believe the patient is competent to endorse checks and direct the use of the proceeds. It also asks whether you, the physician, are related to the patient and, if so, what the relationship is.