Unum's group short term disability claim form carries a 2-page Attending Physician Statement documenting the diagnosis, pregnancy dates, treatment, restrictions and limitations, and expected return to work. Unum treats a claim as complete once it has this statement, the employee's and employer's statements and a signed medical authorization. It aims to make the initial decision on most short term disability claims within five business days of a complete claim.
The physician or treating provider primarily responsible for the patient's care completes the Attending Physician Statement on pages 9 and 10: Section A for pregnancy, B for other conditions, C for functional capacity and D for the signature. The employee completes pages 4 and 5 and the last-page authorization, and the employer completes pages 7 and 8.
The heading says the statement is to be completed by the physician or treating provider, in print. Enter the patient's last name, suffix, first name and middle initial, address, date of birth, telephone number, Social Security number and employer name. Page 10 repeats the name and date of birth fields at the top, so fill them in there as well.
Give the expected and actual delivery dates, delivery type (vaginal or C-section), the date of the first visit for this pregnancy and the date hospitalized. Enter the diagnosis with its ICD code and whether you advised the patient to stop working, with the date. Answer whether complications caused the patient to stop working before the expected delivery date and explain them if so.
Enter the first visit for the current condition and the last and next office visits, whether you advised the patient to stop working and when, any past treatment for the same or a similar condition with dates, whether the condition is work related, and height and weight. Give primary and secondary diagnoses with ICD codes, hospital dates, any surgery with procedure, CPT code and date, and the treatment plan with all medications.
At the top of page 10, list other treating providers you know of or have referred the patient to, with name, specialty, address and phone. Answer whether you have advised the patient to return to work and give the expected return-to-work date, marked full time or part time, with part-time hours per day.
If the patient has no physical or behavioral health restrictions (activities they should not do) or limitations (activities they cannot do), initial the line and go to Section D. Otherwise list current ones against a standard 8-hour workday with breaks about every two hours. Never means not at all, occasional under 33% of the time, frequent 34 to 66% and constant 67 to 100%. Give the From and To dates for the restrictions and limitations.
A fraud notice above this section states that knowingly filing false or misleading information is subject to criminal and civil penalties, including on the Attending Physician portions. Print your name, degree or specialty, 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.
Short 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
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes. Unum publishes a bilingual English and Spanish edition, CL-1104-BL, revision 07/25. It is 18 pages long, and the Attending Physician Statement sits on pages 15 and 16 rather than on pages 9 and 10 of the English-only packet.
Section A, then Section C. Section A asks for the expected and actual delivery dates, delivery type, first visit for the pregnancy, hospital date, diagnosis with ICD code, whether you advised the patient to stop working, and any complications that stopped work before the expected delivery date. Section B is for all other conditions.
Unum aims to make the initial decision on most short term disability claims within five business days after it receives a complete claim. A complete claim includes the employee's statement, the employer's statement, the Attending Physician Statement and a signed medical authorization, so the decision waits on the physician's statement.
Restrictions are activities the patient should not do, and limitations are activities the patient cannot do. Section C asks you to list current ones against a standard 8-hour workday with breaks, using Unum's definitions of occasional, frequent and constant, and to give From and To dates. If there are none, you initial the line and go to Section D.