Trustmark uses this 1-page Attending Physician's Statement when an insured with a terminal illness asks for an early (accelerated) life insurance benefit. The physician records the diagnosis and ICD code, onset and first treatment dates, treatments, medications and any hospitalization. The key line certifies that, after medical review, the patient is terminally ill and expected to survive only a stated number of months.
The attending physician completes and signs the whole statement. The insured files the separate Early Life Insurance Benefit (Terminal Illness) claim form, A112-2515, posted on the same Trustmark page.
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Early Benefits – Life Claim (Attending Physician's Statement)
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The physician completes a statement that, after a thorough medical review, the named patient is terminally ill and is anticipated to survive only a stated number of months. The rest of the form supports that conclusion with the diagnosis, ICD code, cause, treatment dates and type, medications and hospitalization.
Yes. Trustmark's forms page lists a separate Accelerated Death Benefit Claim Form, P321-9, for early life insurance benefits for New York residents. A112-2515 and its physician statement appear in the standard Life Insurance Forms section.
Yes. It asks whether the patient is hospitalized, with the dates, hospital name, address and phone number. It also asks for the frequency and type of treatments provided and a list of current medications.