Disability Claim - Attending Physician’s Statement of Disability
Sun Life Assurance Company of Canada, a member of the Sun Life Financial group
of companies, is committed to keeping information concerning this claim confidential. Please print clearly in ink
To be completed by the patient/claimant
Name ________________________________________________________________________________ Date of birth: Day Month Year
Last name First name
Policy/Contract No. __________________ Division __________________ Member ID Control No. ________________
AUTHORIZATION: I authorize my doctor to use and exchange information with Sun Life Assurance Company of Canada, its agents and service
providers for the purposes of underwriting, administration and adjudicating claims under this Plan. I agree that a photocopy or electronic version of this
authorization is as valid as the original.
Patient/Claimant’s signature ______________________________________________________________ Date
Day Month Year
To be completed by the physician If you have completed this form before, please report on only
new or different information dating from your last report.
Diagnosis:
1. Primary: _____________________________________________ Symptoms: _______________________________________________
2. Secondary: __________________________________________ Symptoms: _______________________________________________
3. Other contributing factors/complications: ______________________________________________________________________________________
History:
1. Symptoms began or accident happened on 2. Illness or injury forced cessation of work on
Day Month Year Day Month Year
3. First visit 4. Is this a work-related illness/injury? ❑ No ❑ Yes ❑ Unknown
Day Month Year
5. a) Has patient ever had the same or a similar condition? ❑ Yes ❑ No ❑ Unknown
b) If yes, state when and describe condition ___________________________________________________________________________________
_________________________________________________________________________________________________________________________
6. Has your patient been hospitalized ❑ Yes ❑ No
If yes, please indicate dates to Name of Hospital ________________________________
Day Month Year Day Month Year
________________________________
Current findings
1. When did you most recently examine your patient?
Day Month Year
2. What were your findings on this examination date? ______________________________________________________________________________
_________________________________________________________________________________________________________________________
3. Is your patient: a) Diabetic ❑ Yes ❑ No Insulin dependent ❑ Yes ❑ No
b) Smoker ❑ Yes ❑ No
c) Weight _______ Height _______ In a weight reduction program? ❑ Yes ❑ No
d) ❑ Right handed ❑ Left handed (if applicable to illness/injury)
e) Is the patient receiving or in need of treatment for alcohol or drugs? ❑ Yes ❑ No
If yes, please elaborate on treatment_________________________________________________________________________
f) Is the patient prevented from driving because of a medical condition ❑ Yes ❑ No
4. What functional limitations affect the claimant’s ability to perform his/her normal activities, including work?___________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Was any formal testing done i.e. Functional Abilities Evaluation? If so, please enclose the report and date of the examination.____________________
_________________________________________________________________________________________________________________________
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5. What investigations have been done? Please list specific tests below and attach copies of test results.
Tests done Date performed Summary of results
(e.g., EKG’s, x-rays, lab tests) Day Month Year (Attach copies of all available reports.)
Treatment
1. I see this patient ❑ Weekly ❑ Bi-Weekly ❑ Monthly ❑ Other _______________________________________________________________
I am providing: ❑ Primary care ❑ Consultant care or ❑ Both
2. Identify the current medications and dosages prescribed as well as the response to these medications. ________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
3. Therapy? ❑ Yes ❑ No If “Yes”, indicate type (e.g. physiotherapy, psychotherapy, pain therapy etc.) ______________________________
Frequency: ❑ Daily ❑ ________ x per Week ❑ Other ______________________________________
At: ❑ Outpatient dept. ❑ Therapist’s ❑ Home
4. Surgery? ❑ Yes ❑ No If “Yes”, type of surgery ______________________________________________________________________
date ❑ performed ❑ planned
Day Month Year
5. Any other treatment or future plans for treatment? (Specify with dates.) ______________________________________________________________
____________________________________________________________________________________________________________________________
6. Summarize patient‘s response to treatment ____________________________________________________________________________________
________________________________________________________________________________________________________________________
Has your patient been referred to any other physician(s)/specialist(s)? ❏ Yes ❏ No If yes, complete the following chart and attach a copy
of the report.
Physician’s name and specialty Date of examination Findings
Day Month Year
Prognosis
Have you discussed a return to work plan with your patient? ❑ Yes ❑ No If no, why not? ____________________________________________
________________________________________________________________________________________________________________________
If yes, please provide details about the return to work plan, including approximate time frames. ______________________________________________
________________________________________________________________________________________________________________________
Notice to physician
Any information provided by you to Sun Life Assurance Company of Canada regarding this claim may be disclosed to the patient and/or those authorized by
him/her to receive such disclosure unless you notify us in writing that there is a significant likelihood that such disclosure would result in a substantial adverse
effect on the health of the patient or in harm to a third party.
Physician’s signature ________________________________________________________________________ Date
Day Month Year
Print name _____________________________________________________ Phone number (_________________________________________________
)
Return this form to your patient or send the form to Sun Life Assurance Company of Canada Disability Benefits office. If you fax or mail this form to Sun Life
Assurance Company of Canda, please confirm the appropriate Disability Benefits office with your patient. Thank you for your assistance.
Edmonton: Toronto: Halifax: Montreal: Kitchener/Waterloo: Vancouver:
Fax: 1 866 639-7820 Fax: 1 866 639-7851 Fax: 1 866 639-7850 Fax: 1 866 639-7846 Fax: 1 866 209-7215 Fax: 1 866 639-7829
PO Box 2733 Stn Main PO Box 950 Stn A 1100 - 1809 Barrington St. PO Box 11037 Stn CV PO Box 100 Stn C PO Box 48810 Stn Bentall
Edmonton AB T5J 5C9 Toronto ON M5W 1G5 Halifax NS B3J 3K8 Montreal QC H3C 4W8 Kitchener ON N2G 3W9 Vancouver BC V7X 1A6
490R-P-SL-E-05-04 (G2776-E) Page 2 of 2
