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Assurity Life Insurance Company Disability Claim Form — Attending Physician’s Statement, page 1
Complex · 64/100Form Complexity Index

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What this form asks for

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This is an Assurity Life Insurance Company disability claim medical statement completed by the attending/treating physician(s) who cared for the patient during the period of disability. It captures clinical details such as primary and secondary diagnoses (ICD-9/DSM), symptoms and objective findings, treatment history (medications, surgery, rehab referrals), hospital confinement, pregnancy details (if applicable), and the physician’s assessment of work restrictions/limitations and return-to-work timing. The form is important because insurers use it to evaluate medical eligibility, duration, and severity of disability, and it includes required fraud notices and physician certification/signature. Today, this form can be filled out quickly and accurately using AI-powered services like Instafill.ai, which can also convert non-fillable PDF versions into interactive fillable forms.
Fillable fields145
Pages3
Sections35
Form Complexity IndexComplex, 64/100

The AI checks your answers before you download

16 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Patient identity fields are present and plausibly formatted (Full Name + Date of Birth)

Validates that the patient’s full name is provided (at minimum first and last name) and that the date of birth is complete and in MM/DD/YYYY format (or month/day/year components all present). This is essential to correctly match the claim to the insured/claimant record and avoid misrouting medical information. If missing or malformed, the submission should be rejected or routed to manual review with a request for corrected demographics.

Policy/Certificate number is present and matches allowed policy number pattern

Checks that a policy number (and/or policy/certificate number(s) in the header) is provided and conforms to the insurer’s expected character set/length (e.g., alphanumeric, no illegal symbols, trimmed whitespace). This prevents claims from being created without a reliable key for downstream matching and adjudication. If validation fails, the form should not proceed to automated intake and should prompt for correction.

All date fields use valid calendar dates and consistent MM/DD/YYYY formatting

Validates that every date field (symptom onset, first/last visit, first unable to work, pregnancy dates, confinement dates, signature date) is a real calendar date (e.g., no 02/30, month 01–12, day 01–31) and uses the required format. Correct date parsing is critical for benefit calculations, eligibility windows, and medical timeline analysis. If any date is invalid, the system should flag the specific field and block submission until corrected (or route to exception handling).

Chronological consistency across medical timeline dates

Ensures the sequence of dates is logically consistent: symptoms first appeared should be on/before first visit; first visit should be on/before last visit; first unable to work should not be after last visit (unless clearly documented); and dates should not be in the far future except for expected return-to-work or expected due date. This reduces contradictory timelines that can cause incorrect disability start dates or denials. If inconsistencies are found, require correction or an explanatory note before acceptance.

Primary diagnosis includes a diagnosis text and a valid ICD-9 or DSM code format

Checks that the primary diagnosis field is not blank and includes either an ICD-9 code (commonly 3–5 digits with optional decimal, e.g., 296.3) or a DSM code/identifier consistent with the form’s instructions. Diagnosis coding is required for claim classification, medical necessity review, and analytics. If the code is missing or malformed, the submission should be flagged and the provider prompted to supply a valid code.

Symptoms and objective findings are both completed with clinically meaningful content

Validates that the Symptoms and Objective Findings fields are not empty and contain more than placeholder text (e.g., not just 'N/A' unless accompanied by an explanation). These fields support the medical basis for disability and are often required for claim approval. If either is missing or too short to be meaningful, the system should request additional detail or route to manual review.

And 10 more checks
  • Secondary conditions dependency: Yes requires details; No requires details to be blank or 'None'
  • Work-related condition dependency: explanation required when marked Yes
  • Surgery history logic: prior surgery details required if 'Has undergone surgery' = Yes; future surgery only allowed if prior surgery = No and future surgery = Yes
  • Hospital confinement dependency and completeness (facility + dates + times)
  • Hospital confinement date/time consistency (start ≤ end; admission time precedes dismissal time when same day)
  • Referring physician dependency: if referred = Yes, require referring physician name and full address
  • Physician contact information format (phone/fax) and required physician identity fields
  • Return-to-work dates and work incapacity date consistency
  • Self-care prevention dependency: if 'Prevents self-care' = No, expected change timeline selection is required
  • Signature, signature date, and TIN/SSN presence and format validation

Let AI fill out your Assurity Attending Physician’s Statement (01-014-02255F R10-22)

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How to Fill Out Assurity Attending Physician’s Statement (01-014-02255F R10-22) Online for Free in 2026

What the AI walks you through.

  1. Go to Instafill.ai and upload the Assurity Disability Claim Form — Attending Physician’s Statement (or select it from the form library).
  2. Let the AI detect and map the form fields (patient identifiers, policy/certificate numbers, diagnoses, dates of visits, and treatment sections).
  3. Enter or import the patient and claim details (patient name, DOB, policy number, claimant name) and confirm accuracy.
  4. Complete the medical sections with AI assistance: symptoms, objective findings, primary/secondary diagnoses (ICD-9/DSM), treatment frequency, medications, surgery history/future surgery, referrals, and hospital confinement details (if applicable).
  5. Fill the work capacity section: restrictions (should not do), limitations (cannot do), first unable-to-work date, expected improvement timeline, and full-time/part-time return-to-work dates.
  6. Review the fraud notice acknowledgments and physician information (name, degree, specialty, address, phone/fax), then add the physician signature/date and TIN/SSN as required.
  7. Run a final validation check, download the completed PDF, and submit it to Assurity via the instructed claims channel (fax/mail) while saving a copy for records.

Common Mistakes in Completing Assurity Attending Physician’s Statement (01-014-02255F R10-22)

The ones the AI is built to catch.

Missing or incorrect policy/certificate number
People often leave the Policy No./Policy/Certificate no.(s) blank or copy a number from the wrong document (e.g., group certificate vs. individual policy). This can delay matching the Attending Physician’s Statement to the correct claim file and may trigger follow-up requests from the claims department. Always copy the number exactly as shown on the claimant’s policy/certificate and include all digits/letters; AI tools like Instafill.ai can help by validating expected formats and preventing transposed characters.
Patient identity details don’t match insurer records
A common issue is entering nicknames, omitting the middle name/initial, or misspelling the claimant’s name, and occasionally mixing up “claimant” vs. “patient” fields when someone else is completing the paperwork. Mismatches can cause processing delays, requests for clarification, or misfiling into the wrong claim. Use the patient’s legal name as it appears on the policy and ensure the same name is used consistently across all pages; Instafill.ai can standardize names and reduce inconsistencies.
Date format errors and inconsistent timelines (MM/DD/YYYY)
This form requires MM/DD/YYYY in multiple places (DOB, symptom onset, first/last visit, first unable to work, pregnancy dates, hospital confinement dates), and people frequently enter DD/MM/YYYY, partial dates, or conflicting sequences (e.g., “last visit” earlier than “first visit”). Inconsistent timelines can undermine medical credibility and lead to claim delays or additional documentation requests. Double-check that all dates are complete, in MM/DD/YYYY, and chronologically consistent; Instafill.ai can auto-format dates and flag impossible sequences.
Diagnosis entered without the required ICD-9 or DSM code
Providers sometimes write only a narrative diagnosis (e.g., “back pain” or “depression”) and omit the ICD-9 or DSM code, or they include an ICD-10 code even though the form asks for ICD-9/DSM. Missing or incorrect coding can slow adjudication because the insurer may need clarification to classify the condition and evaluate benefits. Include the primary diagnosis plus the corresponding ICD-9 or DSM code exactly as requested; Instafill.ai can help by prompting for the correct code type and formatting.
Symptoms and objective findings are too vague or swapped
A frequent mistake is listing subjective complaints under “Objective Findings” (or leaving objective findings blank) and using generic phrases like “pain” or “limited ROM” without measurements, test results, imaging, or exam findings. Weak or miscategorized clinical support can lead to follow-up requests, independent medical review, or delays in determining functional impairment. Separate subjective symptoms from objective evidence and include specifics (e.g., MRI findings, strength grades, ROM degrees, lab values); Instafill.ai can guide structured entry so each section contains the right type of information.
Secondary conditions checkbox conflicts with the written explanation
People often check “No” for secondary conditions but then mention comorbidities elsewhere (or check “Yes” and leave the “If YES, what are they?” line blank). These inconsistencies create ambiguity about what is contributing to disability and can prompt insurer outreach for clarification. Ensure the Yes/No selection matches the narrative and list each contributing condition with a brief impact statement; Instafill.ai can flag missing conditional fields when “Yes” is selected.
Work-related condition marked ‘Yes’ without a clear mechanism/explanation
When “Is the patient’s condition work related?” is checked “Yes,” the explanation is often missing or too minimal (e.g., “work injury”) without duties, exposure, event date/timeframe, or mechanism. Insufficient detail can delay coordination with workers’ compensation, subrogation review, or claim eligibility determinations. If work-related, describe the job tasks/exposures, what happened, and approximate dates; if not work-related, clearly state “Not work-related.”
Surgery section completed incorrectly (past vs. future surgery logic)
A common error is checking “Has the patient undergone surgery? Yes” but not providing date/procedure/result, or checking “No” and then forgetting to complete the “do you expect surgery in the future?” follow-up (or entering future surgery details even when “No” is selected). This creates gaps in treatment history and can affect disability duration and prognosis assessment. Follow the conditional flow: past surgery requires date/procedure/result; no past surgery plus expected future surgery requires anticipated date/type; Instafill.ai can enforce these conditional requirements.
Medication list missing dosage and frequency
Providers often list only medication names (or “see chart”) and omit dose, route, and frequency, despite the form explicitly requesting frequency and dosages. Missing medication details can hinder evaluation of treatment intensity, side effects, and functional impact, leading to requests for records or clarification. List each medication with strength and schedule (e.g., “Sertraline 50 mg PO daily”); Instafill.ai can format medication entries consistently and ensure required components are present.
Restrictions vs. limitations are confused or not tied to job function
Many forms contain generic statements (e.g., “no work,” “limited activity”) or mix up restrictions (what the patient should not do) with limitations (what the patient cannot do), without functional specifics like lifting limits, standing/walking tolerance, or cognitive constraints. Vague functional statements can delay benefit decisions because the insurer cannot map impairment to occupational duties. Provide measurable, task-based restrictions/limitations and align them with the condition; Instafill.ai can prompt for structured functional details and reduce ambiguity.
Signature/date/TIN requirements missed or completed incorrectly
The form requires the physician’s signature (no stamp), date (MM/DD/YYYY), and TIN or Social Security No., and these are frequently left blank, stamped, or dated incorrectly. Missing authentication can invalidate the statement and force rework, delaying claim processing. Ensure the attending physician signs by hand (or per accepted e-sign process if allowed), dates it in MM/DD/YYYY, and provides the correct TIN/SSN; Instafill.ai can remind users of required end-of-form fields and reduce omissions.

Frequently Asked Questions About Assurity Attending Physician’s Statement (01-014-02255F R10-22)

 

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How does the AI fill out Assurity Attending Physician’s Statement (01-014-02255F R10-22)?
You answer a few questions in plain words, or upload a document you already have. The AI reads what you give it and puts each answer into the right field of Assurity Attending Physician’s Statement (01-014-02255F R10-22), on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.
What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is Assurity Attending Physician’s Statement (01-014-02255F R10-22) to fill out?
Assurity Attending Physician’s Statement (01-014-02255F R10-22) has a Form Complexity Index of 64 out of 100, in the complex tier: 145 fillable fields across 3 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is the Assurity Disability Claim Form – Attending Physician’s Statement used for?
This form provides medical information Assurity needs to evaluate a disability claim, including diagnosis, treatment, and work restrictions/limitations. It must be completed by the physician(s) who treated the claimant during the period of disability.
Who is supposed to fill out this Attending Physician’s Statement—me or my doctor?
Your attending physician (and any other treating physicians during the disability period) should complete it. The form notes that the patient is responsible for ensuring it is completed and that any physician fees are not paid by Assurity.
Do all treating physicians need to complete a separate form?
Yes—this statement should be completed by all physicians who treated the claimant during the time of disability. If you saw multiple providers (e.g., primary care and specialist), each may need to submit their own statement.
What key information is required in Section A (General Information)?
Section A asks for the patient’s full name, policy number, date of birth, and the primary diagnosis including the ICD-9 or DSM code. Make sure the policy number matches the claimant’s insurance documents.
What should be included under “Symptoms” and “Objective Findings”?
Symptoms should describe what the patient reports (onset, severity, frequency, and triggers). Objective findings should include exam findings and test results that support the diagnosis (e.g., imaging, labs, measurements, or observed clinical signs).
How do we answer the question about secondary conditions contributing to inability to work?
If other conditions (comorbidities) also limit the patient’s ability to work, check “Yes” and list them with a brief explanation of how they contribute. If none, check “No” and leave the details blank.
What dates does the form ask for regarding visits and work incapacity?
The form requests the date symptoms first appeared, the first and last visit dates for this condition, how often the physician treats/consults, and the date the physician believes the patient was first unable to work. Use MM/DD/YYYY format for all dates.
What if the condition is work-related—what details are needed?
If it is work-related, check “Yes” and briefly explain how it relates to the job (e.g., duties, exposure, injury mechanism, and approximate timeframe). If it is not work-related, check “No” (or write “Not work-related” if a narrative is requested).
How should surgery, medications, and other treatments be documented?
If surgery occurred, include the date, procedure, and result; if no surgery but one is expected, provide the anticipated date and type. List all current medications with dosage and frequency, and describe other treatments (e.g., PT, injections) with how often they occur.
When do we fill out the hospital confinement section?
Complete it only if the patient was hospital confined for the condition. You’ll need the hospital name and address, confinement start and end dates, and admission/dismissal times.
What is the mental impairment classification and DSM-IV-R Axis I–V section for?
This section is used when the disability involves a mental impairment. The physician selects a class (1–5) describing limitation severity and may provide DSM-IV-R Axis I–V diagnoses, including psychosocial factors (Axis IV) and overall functioning (Axis V).
Do we need to complete the pregnancy section (Section C) for every claim?
No—Section C is only for pregnancy-related disability claims. It asks for LMP, first treatment date, due date, delivery date/type, and any pregnancy/delivery/postpartum complications.
How do we complete the “restrictions” vs. “limitations” part in Section D?
Restrictions are activities the patient should not do (e.g., no lifting over 10 lbs, no driving). Limitations are activities the patient cannot do at all due to the condition (e.g., cannot stand more than 10 minutes, cannot concentrate for sustained tasks).
Where does the physician sign, and are signature stamps allowed?
The physician must sign and date on the signature line near the fraud notice acknowledgment and certification. The form specifies “Physician’s Signature (no stamp),” so a stamped signature should not be used.
Can AI tools help fill out this form, and how can I use Instafill.ai if the PDF isn’t fillable?
Yes—AI tools can help organize and auto-fill form fields accurately; services like Instafill.ai can save time by mapping your information into the correct fields. If the PDF is flat/non-fillable, Instafill.ai can convert it into an interactive fillable form and then guide you to upload the PDF, enter the patient/claim details, and export a completed version for the physician to review, sign, and submit.
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company forms: Form S-1, Surety Company Annual Report, National Integrity Life Insurance Company Ownership Change Request Form (NI-77-0039-2505), QBCC Licence Application Form – Company (Application made under section 33, Queensland Building and Construction Commission Act 1991), California Form 568 (2024), Limited Liability Company Return of Income, Continental American Insurance Company (CAIC) / Aflac Group Critical Illness Claim Form (with Attending Physician’s Statement, HIPAA Authorization to Obtain Information, and Electronic Funds Transaction Authorization), Brotherhood Mutual Insurance Company Ministry Driver Screening Form (A99), Due Diligence Form (Australian Company) – The Perth Mint, The Prudential Insurance Company of America Group Disability Insurance – Education and Employment History Form (GL.2009.009, Ed. 06/2017), Pennsylvania Department of State — Certificate of Termination (Domestic Limited Liability Company) (15 Pa.C.S. § 8872(f)) (DSCB:15-8872(f)), Louisiana Secretary of State – Notice of Change of Registered Office and/or Change of Registered Agent (Domestic Limited Liability Company) (R.S. 12:1308) (Form SS983, Rev. 01/24), Form LLC1050, Articles of Cancellation of a Virginia Limited Liability Company, HDFC ERGO General Insurance Company Limited – Request for Cashless Hospitalisation for Health Insurance (Policy Part – C), Anmeldung zum R+V-Firmenportal Vorsorge (Registration for the R+V Company Portal for Pensions), Beneficiary Designation/Change - Principal Life Insurance Company, Principal Life Insurance Company UCTIE INTERNATIONAL UNION 401(K) SAVINGS PLAN Enrollment Form, Principal Life Insurance Company Death Notification Form, Principal Life Insurance Company Form PG4701, In-Plan Roth Conversion – No Spousal Consent Needed, Principal Life Insurance Company Administration Guide, Principal Life Insurance Company Small Amounts Benefit Election, SEC Application for an Order under Section 17(b) of the Investment Company Act of 1940 (File No. 812-11000)

NJ state forms: Form 1095-A, Health Insurance Marketplace Statement, Form W-2, Wage and Tax Statement, Form 593, Real Estate Withholding, Form 8938, Statement of Specified Foreign Financial Assets, Form CMS-2567, Statement of Deficiencies, Form 1098, Mortgage Interest Statement, Form 1098-T, Tuition Statement, Form 1099-S, Proceeds From Real Estate Transactions, Form 1098-E, Student Loan Interest Statement, Form DS-3053, Statement of Consent, Form DS-86, Statement of Non-Receipt of a U.S. Passport, Form DS-86, Statement of Non-Receipt of a U.S. Passport, Form 108, Statement of Intention, Form 107, Statement of Financial Affairs, Form 121, Statement About Your SSNs, Form 122A-1, Chapter 7 Statement of Current Monthly Income, Center for Infertility & Reproductive Surgery – New Patient Questionnaire and Patient/Guarantor Statement (Brigham and Women’s Hospital, Department of Obstetrics and Gynecology), Adult Travel Document Application for Stateless and Protected Persons in Canada (16 years of age or over) (PPTC 190), Form W-8IMY (Rev. October 2021), Certificate of Foreign Intermediary, Foreign Flow-Through Entity, or Certain U.S. Branches for United States Tax Withholding and Reporting, Form W-2, Wage and Tax Statement (2025)

state ID forms: Application for Renewal or Duplicate of Alabama Driver License or ID card, Form 1095-A, Health Insurance Marketplace Statement, Form W-2, Wage and Tax Statement, Form 593, Real Estate Withholding, Form 8938, Statement of Specified Foreign Financial Assets, Form CMS-2567, Statement of Deficiencies, Form 1098, Mortgage Interest Statement, Form 1098-T, Tuition Statement, Form 1099-S, Proceeds From Real Estate Transactions, Form 1098-E, Student Loan Interest Statement, Form DS-3053, Statement of Consent, Form DS-86, Statement of Non-Receipt of a U.S. Passport, Form 108, Statement of Intention, Form 107, Statement of Financial Affairs, Form 121, Statement About Your SSNs, Form 122A-1, Chapter 7 Statement of Current Monthly Income, Center for Infertility & Reproductive Surgery – New Patient Questionnaire and Patient/Guarantor Statement (Brigham and Women’s Hospital, Department of Obstetrics and Gynecology), Adult Travel Document Application for Stateless and Protected Persons in Canada (16 years of age or over) (PPTC 190), Form W-8IMY (Rev. October 2021), Certificate of Foreign Intermediary, Foreign Flow-Through Entity, or Certain U.S. Branches for United States Tax Withholding and Reporting, Form W-2, Wage and Tax Statement (2025)

end of life forms: Texas Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order

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