Unum uses this 11-page form for group critical illness and specified disease claims, including cancer. The Attending Physician Statement on pages 8 to 10 records the diagnosis, ICD code and diagnosis date, then lists the medical documentation Unum needs for each covered condition. It ends with a return to work assessment, hospitalization and surgery details, and the physician's signature.
The attending physician or treating provider completes and signs pages 8 to 10. The employee completes the Employee/Patient Statement on pages 4 to 6 and signs the authorization; Be Well screening benefit claims do not need the physician statement.
Download the current version from the source each time; forms change without notice.
Group Critical Illness 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.
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For heart attack (myocardial infarction), the physician statement lists medical records, surgical records, elevated biochemical markers and imaging studies. Coronary artery disease needs the diagnosis and type of surgery recommended, and sudden cardiac arrest needs the hospital admission and discharge summary with treatment notes.
The claim form lists child conditions including cerebral palsy, cleft lip or palate, congenital heart disease, cystic fibrosis, Down syndrome, sickle cell anemia, spina bifida and type 1 diabetes. The physician statement asks for a clinical diagnosis made or confirmed after birth.