Unum uses this claim form for voluntary benefits and group critical illness or specified disease coverage and for voluntary benefits and group cancer coverage, and one form covers a patient insured under several of them. The attending physician confirms the diagnosis, its date and the evidence for it, such as a pathology or surgical report. The benefit is a lump sum paid directly to the insured.
The physician or treating provider primarily responsible for the patient's care completes the Attending Physician Statement on pages 8 and 9. The insured completes the Insured/Patient Statement on pages 4 to 6 and signs the authorization on the last page.
Unum asks you to complete all applicable questions, provide copies of supporting reports such as office notes, medical records, consultations or testing, and sign and date the form. Enter the insured's name and Social Security number, then the patient's, since the patient can be the insured, a spouse, a domestic partner or a child. Add the patient's relationship to the insured, gender and date of birth.
This part is completed for all medical conditions. Enter the diagnosis with its ICD code, the date of diagnosis and the date you were first consulted for the condition. Directly below, the form asks you to check each condition that applies and provide the test results, operative reports, pathology reports or detailed medical statement required for it.
Check each condition that applies and supply the documentation listed beside it. Cancer and carcinoma in situ need a pathology report or clinical diagnosis, and cancer also asks for stage and grade. Blindness needs corrected visual acuity and visual field restriction for each eye. Coma asks about 14 or more consecutive days of unconsciousness and intubation, end stage renal failure about dialysis, and major organ failure about the UNOS list and date added.
Answer whether you advised the patient to stop work and when, and whether you have advised a return to work, with the expected date and full-time or part-time status. If the patient is returning, list ongoing restrictions and limitations on the next page; if not, list the restrictions and limitations that prevent the return.
At the top of page 9, repeat the insured's and patient's names and dates of birth. Then describe current restrictions (activities the patient should not do) and current limitations (activities the patient cannot do). The form asks you to be specific in both boxes, which follow from your answers in the Return to Work Assessment.
Answer whether another physician has treated the patient for the same or a similar condition, and list other treating physicians or hospitals with specialty, address, phone, fax and treatment dates. Give any hospital stay with dates and facility, any surgery with CPT-4 codes and date, and whether the patient is still under your care or the final date of treatment.
Read the fraud notice, which applies to the Attending Physician portions of the claim form. Print your name, medical specialty, degree, address, telephone and fax numbers and Tax ID number, answer whether you are related to the patient, and sign and date to confirm the statements are true and complete.
Download the current version from the source each time; forms change without notice.
Critical Illness/Specified Disease Claim Form
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.
Sources for this guide
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It depends on the condition checked. The statement lists the documentation for each: a pathology report or clinical diagnosis for cancer, a tissue biopsy for a benign brain tumor, EKG, cardiac enzymes, thallium or MUGA scans or stress echocardiogram for a heart attack, documented neurological deficits or neuroimaging for stroke, and a surgical report for coronary artery bypass or major organ transplant.
Yes. The instructions list four claim types: voluntary benefits critical illness or specified disease, voluntary benefits cancer, group critical illness or specified disease, and group cancer. A person covered by more than one of these products completes only this one form.
Not Unum. The form's instructions state that Unum is not responsible for expenses associated with completing the Attending Physician Statement. The critical illness or cancer benefit itself is a lump sum paid to the insured, and a claim for the health screening benefit alone does not need the physician statement at all.
The checklist includes benign brain tumor, blindness, cancer, carcinoma in situ, cerebral palsy, cleft lip or palate, coma, coronary artery bypass surgery, cystic fibrosis, Down syndrome, end stage renal failure, heart attack, major organ transplant or failure, occupational HIV, permanent paralysis, spina bifida and stroke. Which ones a patient's policy covers depends on the plan.