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Trustmark A112-2511 Long-Term Care Claim Physician APS

Trustmark uses this 13-page claim when an insured on one of its universal life policies (LifeEvents or Life + Care) claims the long-term care or home health care benefit. Eligibility generally rests on loss of independence in activities of daily living or cognitive impairment needing another person's help or supervision. The attending physician's 3-page statement rates each ADL and describes any cognitive impairment.

Who completes it

The physician primarily responsible for the patient's care completes the Attending Physician Statement, sections A to E, and signs section E. The insured or an authorized representative completes the Insured's Statement of Loss, the disclosure authorization and the claim submission signature.

Submitting and payment

How to submit it
Send the claim to Trustmark's life claims unit by fax, email or mail, using the contacts printed on each page. Trustmark also accepts claims online.
Who pays
The claim form lists no fee, billing code or Trustmark payment for the physician's statement.

Good to know

  • Each ADL (bathing, dressing, taking medication, toileting, eating, transferring) is rated 0 to 3, with the date loss began and when improvement is expected.
  • The form asks whether your opinion rests on clinical observation, functional evaluation or testing, or patient and family report.
  • The cognitive section asks whether impairment puts the patient at risk for health and safety, current supervision hours and days, the diagnosis type, and for any cognitive testing.
  • New York residents use a different Trustmark form, the Convalescent Care Benefit Claim Form P383-24.

Get the official form

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

Long-Term Care / Home Health Care Claim (Life)

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.

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Frequently asked questions

How do I rate ADLs on the Trustmark A112-2511 statement?

Use the form's 0 to 3 scale: 0 means the person can do the whole activity with or without equipment, 1 needs supervision, 2 needs actual help from someone, and 3 is mostly or completely dependent. Trustmark notes that assistance can be stand-by or hands-on.

What else does the Trustmark long-term care claim need besides the physician statement?

The instructions ask for a signed health care or durable power of attorney if applicable, a copy of the nursing home, assisted living or home health agency license, and any testing or neuropsychological evaluations. Trustmark may ask the insured and providers for more information.

Does the Trustmark form ask whether I recommended long-term care?

Yes. It asks whether you recommended long-term care or home health care services, such as home care, adult day care or a nursing home, within the last 12 months, the date and services recommended, and whether the patient complied.