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 |
Created: February 11, 2026 07:49 PM
