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Trustmark A112-2497 Critical Illness/Cancer Claim APS

Trustmark Voluntary Benefits uses this claim packet when a policy owner files under a Trustmark critical illness and cancer policy. The physician primarily responsible for the patient's care completes a 3-page Attending Physician's Statement with the diagnosis date and condition-specific questions for ALS, blindness, cancer, coronary artery bypass, end stage renal failure, heart attack, major organ failure, occupational HIV, paralysis and stroke.

Who completes it

The physician primarily responsible for the patient's care completes the Attending Physician's Statement, including all treatment dates, signature and date. The policy owner completes Sections A to D and the claim submission signature, and the patient signs the disclosure authorization.

Submitting and payment

How to submit it
Return the packet to Trustmark Voluntary Benefits by fax or email using the claims contacts printed on each page. Trustmark prefers online filing and posts these forms for people who cannot file online.
Who pays
The instructions state that the policy owner is responsible for completing all portions of the form without expense to Trustmark.

Good to know

  • Attach the reports each condition calls for; the heart attack questions ask about new EKG findings, elevated CPK or troponins, and confirmatory lab reports.
  • For stroke, describe the initial objective neurologic deficit, imaging results and any deficit persisting 30 or more days, with the date of the last neurologic exam.
  • Trustmark notes that a checked condition does not guarantee benefits; benefits are determined by the policy provisions.
  • The policy owner lists all physicians and facilities that treated the patient in the last ten years. Health Screening Rider claims use separate form A112-2501.

Get the official form

Download the current version from the source each time; forms change without notice.

Critical Illness / Cancer Claim

Official pagePDF

How this list is checked

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What does the Trustmark A112-2497 physician statement ask for cancer?

For cancer or carcinoma in situ, the statement asks for the date and documented exact pathologic diagnosis. If the cancer was diagnosed clinically instead, it asks for the date, the reason and the treatment recommended. Trustmark's instructions also ask that pathology reports be included with the claim.

Does the physician answer every condition on the Trustmark critical illness form?

No. Complete the section for each condition that applies to the patient and provide the test results, operative reports or pathology reports it requires. You also give the date of diagnosis, when the patient first consulted you, prior similar conditions and any hospitalization dates.

What contact details does the Trustmark statement ask from the physician?

The signature page asks for your name, degree, specialty, address, phone, fax and SSN or employer ID, plus an office manager or other contact for follow-up. It also asks whether Trustmark may email you and whether you are related to the patient.