Unum uses this claim form for group long term disability and for any combination of long term disability, individual disability insurance and life insurance waiver of premium, so a patient covered by several of them needs only this one form. Its Attending Physician Statement records the diagnosis, physical and behavioral health restrictions and limitations, and other treating providers. Unum uses it to make the disability determination.
The physician or treating provider primarily responsible for the patient's care completes the Attending Physician Statement on pages 13 to 15, Sections A to D. The employee completes the employee statement and authorization, and the employer completes the employer statement on pages 10 to 12.
The statement opens with Unum's instructions: complete, sign and date the form, answer all questions, and provide copies of supporting reports such as office notes, medical records, medication logs, consultations or testing. Its stated purpose is to help Unum make a disability determination. Then enter the patient's name, Social Security number, address, date of birth, telephone number and employer name.
Give the dates of the first visit for the current condition and of the last and next office visits, whether you advised the patient to stop working and from when, any past treatment for the same or a similar condition with dates, whether the condition is work related, and height and weight. Enter the primary diagnosis that may affect functional capacity with its ICD or DSM code, other such diagnoses with ICD codes (or NA), hospital dates, and any surgery with CPT code and date.
If the patient has no physical or behavioral health restrictions or limitations, initial the line and go to Section D. Otherwise list current physical restrictions (activities the patient should not do) and limitations (activities the patient cannot do) against a standard 8-hour workday with breaks about every two hours. Use Unum's definitions: occasional is under 33% of the time, frequent 34 to 66% and constant 67 to 100%. Give From and To dates.
List current behavioral health restrictions and limitations separately, with their own From and To dates. Below both lists, state the diagnostic or clinical findings that support the restrictions and limitations, and describe the treatment plan, including all medications. Unum asks you to quantify terms such as 'prolonged', 'repetitive', 'light-duty', 'heavy lifting' or 'stressful situations' rather than using them alone.
Give the complete name, specialty, and city and state of any other treating physicians, facilities or hospitals involved in the patient's care. This section is on page 15, which repeats the patient's name and date of birth at the top and continues with the fraud notice and Section D.
The fraud notice above this section says that knowingly filing false or misleading information is subject to criminal and civil penalties and includes the Attending Physician portion. Enter your printed 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.
Long Term Disability Claim Form (Attending Physician Statement)
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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Yes. The form's instructions say it covers long term disability, or any combination of long term disability, individual disability and life insurance waiver of premium, and that a person covered for more than one of these products completes only this form. Unum's forms library lists it as 'Claim - LTD Disability'.
Yes. The bilingual English and Spanish edition, CL-1019-BL, revision 05/26, is 25 pages long, with the Attending Physician Statement on pages 20 to 22. The English-only CL-1019 is 16 pages, with the physician's pages at 13 to 15.
Unum asks you not to. Section B states that a reply of 'no work' or 'totally disabled' will not enable it to evaluate the claim and may lead Unum to contact you for clarification. List the specific activities the patient should not do and cannot do, quantified against an 8-hour workday, with From and To dates.
The instructions at the top of the statement ask for copies of supporting reports, such as office notes, medical records, medication logs, consultations and testing. Section B also asks which diagnostic or clinical findings support the restrictions and limitations you list, and for the treatment plan with all medications.