Unum uses this 11-page form for voluntary benefits (worksite) disability claims, voluntary life waiver of premium, or both. In the Attending Physician Statement on pages 7 to 9, the patient completes Part I and the physician completes Part II. Part II covers normal pregnancy dates or the diagnosis and findings for other conditions, plus treatment, a functional capacity grid and a return to work assessment.
The physician or treating provider primarily responsible for care completes and signs Part II after the patient fills in Part I. The employee completes the Employee Statement on pages 4 to 6 and signs the authorization.
Download the current version from the source each time; forms change without notice.
Voluntary Benefits Disability Claim Form (Attending Physician Statement)
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Yes. Unum publishes a bilingual English and Spanish edition under form number CL-1064-BL in its forms library. The English-only CL-1064, revision 05/26, runs 11 pages with the Attending Physician Statement on pages 7 to 9.
The instructions state that Unum is not responsible for expenses associated with completing the form. Any fee a practice charges for completing the Part II statement is therefore not paid by Unum.
It asks whether you advised the patient to return to work, the expected date, full or part time and hours per day. If yes, list ongoing restrictions and limitations; if no, list those that keep the patient from returning to work.