Assurity Life Insurance Company Disability Claim Form — Attending Physician’s Statement Completed Form Examples and Samples
Explore detailed examples and samples of the Assurity Life Insurance Company Disability Claim Form — Attending Physician’s Statement. Our filled-out templates guide physicians and claimants on how to accurately complete the form for various medical conditions, ensuring all necessary information is provided for a disability claim.
Assurity Disability Claim Form Example – Attending Physician's Statement for Carpal Tunnel Syndrome
How this form was filled:
This is a sample of a completed Attending Physician's Statement for an Assurity disability claim. It shows how an orthopedic surgeon would document a patient's condition, treatment, and functional limitations resulting from severe bilateral carpal tunnel syndrome requiring surgery, leading to an inability to perform their office-based job.
Information used to fill out the document:
- Patient Name: Jane E. Smith
- Patient Date of Birth: 05/20/1985
- Primary Diagnosis: Severe Bilateral Carpal Tunnel Syndrome
- ICD-10 Code: G56.03
- Date of First Symptoms: 10/10/2025
- Date of First Consultation for this Condition: 01/15/2026
- Patient's Last Day Worked: 03/08/2026
- Date Disability Began: 03/09/2026
- Surgery Performed: Right Carpal Tunnel Release
- Date of Surgery: 03/10/2026
- Is Patient Competent to Endorse Checks/Direct Benefits?: Yes
- Physical Restrictions: Patient is unable to perform fine motor tasks, including typing, writing, or gripping with the right hand. No lifting, pushing, or pulling greater than 5 lbs. Repetitive hand/wrist motion is contraindicated.
- Expected Return to Work (Light Duty): 08/01/2026
- Expected Return to Work (Full Capacity): 10/01/2026
- Attending Physician's Name: Alan Jones, M.D.
- Physician's Specialty: Orthopedic Surgery
- Physician's NPI Number: 1234567890
- Office Address: 456 Ortho Lane, Suite 200, Medville, USA 98765
- Signature Date: 04/05/2026
What this filled form sample shows:
- Clear articulation of the primary and any secondary diagnoses with corresponding ICD-10 codes.
- Detailed description of the patient's subjective symptoms (pain, numbness) and objective findings (positive Tinel's/Phalen's signs).
- Specific dates for the onset of illness, first treatment, and last day worked, establishing a clear disability timeline.
- Precise enumeration of functional limitations and restrictions directly related to the patient's occupational duties as an Office Manager.
- A projected, multi-stage return-to-work plan, including dates for both light-duty and full-capacity work.
Form specifications and details:
| Form Name: | Assurity Life Insurance Company Disability Claim Form — Attending Physician’s Statement |
| Use Case: | Short-Term Disability claim for an office worker following surgery for Carpal Tunnel Syndrome. |
| Medical Specialty: | Orthopedic Surgery |
| Categories: | company forms, disability claim forms, disability forms, disability insurance forms, end of life forms, insurance claim forms, insurance forms, life insurance forms, NJ state forms, PA state forms, physician forms, state ID forms, VA claim forms |
| Created: | February 11, 2026 07:49 PM |