Trustmark Voluntary Benefits uses this 10-page packet to keep paying an open worksite disability claim. The policy owner reports current impairment, daily activities, hospital stays, other treaters and other benefits. The attending physician's 2-page statement (A112-2516-APS) updates diagnosis, treatment, status and restrictions, then certifies total or partial inability to work with dates and a return to work prognosis.
The physician completes the Attending Physician Statement on the last two pages and signs page 2 of the statement. The policy owner completes Sections A and B, the disclosure authorization and the claim submission signature.
Download the current version from the source each time; forms change without notice.
Disability Benefits Continuance Claim
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Section III asks you to certify, based on your impairment and restriction answers and your knowledge of the patient's job, either total or partial inability to work, with from and to dates and a return to work prognosis. You can also refrain from certifying work capacity at this time.
Only the Attending Physician Statement on the last two pages, marked A112-2516-APS. The first eight pages belong to the policy owner: claimant and claim information, e-sign consent, state fraud language, disclosure authorization, third party authorization and the claim submission signature.