Unum uses this 18-page form when an employer and employee ask that group life insurance premiums be waived because the employee is totally disabled. Unum asks for the claim when the employee appears likely to stay totally disabled beyond the policy's elimination period. The Attending Physician Statement on pages 7 to 9 documents diagnosis, functional capacity, treatment and other treating providers.
The physician or treating provider primarily responsible for care completes sections A to D and signs section D. The employer completes the Employer Statement on pages 4 to 6, and the employee completes the Employee Statement, a work experience questionnaire and the authorization.
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Group Life - Disability Benefit Claim Form (Attending Physician Statement)
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Unum says claim forms should be submitted when it appears the employee will be totally disabled beyond the elimination period defined in the policy. Proof of total disability must be received no later than the time frames in the policy following the employee's date of loss.
Only the Attending Physician Statement on pages 7 to 9: patient information and diagnoses with ICD or DSM codes, functional capacity with physical and behavioral health restrictions and limitations, supporting findings and treatment plan, other treating providers, and the signed attestation in section D.