Assurity Life Insurance Company Disability Claim Form — Attending Physician’s Statement Instructions

Enter any additional comments or details the physician wishes to provide about the patient’s condition, treatment, restrictions, prognosis or expected improvement that are not captured elsewhere on the form.

Describe psychosocial and environmental problems affecting the patient (Axis IV), using short phrases or commonly used problem codes (for example, unemployment, family conflict).

Enter the patient’s current DSM-IV-R Axis I diagnosis as a brief diagnostic name or code (for example, Major depressive disorder or 296.3).

Provide the patient’s Axis V Global Assessment of Functioning (GAF) level or a brief description of overall functioning (commonly recorded as a numeric score or short descriptor).

Enter the patient’s DSM-IV-R Axis II diagnosis (personality disorder or developmental disorder) as a brief diagnostic name or code.

List any relevant general medical conditions related to the psychiatric presentation (Axis III) as brief condition names or codes.

Check this box when the patient has a DSM‑IV‑R Axis V (global assessment of functioning) rating and you are entering that rating on the adjacent line.

Check this box when the patient has a DSM‑IV‑R Axis II diagnosis and you are entering that diagnosis on the adjacent line.

Check this box when the patient has a DSM‑IV‑R Axis III (general medical) diagnosis and you are entering that diagnosis on the adjacent line.

Check this box when the patient has DSM‑IV‑R Axis IV psychosocial or environmental problems and you are entering those problems on the adjacent line.

Check this box when the patient has a DSM‑IV‑R Axis I diagnosis and you are entering that diagnosis on the adjacent line.

If future surgery is expected, enter the anticipated date and the type/name of the surgical procedure and any brief relevant details; leave blank if not applicable. Fill only if 'Expected Future Surgery - Yes', 'Has the patient undergone surgery? — No' Has the patient undergone surgery? is 'No' and If no, do you expect surgery to be performed in the future? is 'Yes' (all).

Check this box if you (the physician) expect that surgery will be performed for the patient in the future.

Check this box if you (the physician) do not expect that surgery will be performed for the patient in the future.

Describe in detail the expected course of the patient’s condition, including whether improvement or deterioration is anticipated, the nature and timeline of those changes, and any relevant clinical factors or interventions that will affect the prognosis. Fill only if 'Prevents self-care — No' is 'No'.

Enter the left footer text or current page marker as shown in the form (typically the page or section indicator appearing in the lower-left corner).

Enter the continuation instruction or target page number that appears in the lower-right footer (for example, the text telling the user which page to continue to).

Enter the short left-hand footer label or code shown in the bottom-left corner of the page (for example a section or form identifier).

Enter the footer message that instructs navigation to the next page (for example 'Continue to page 2 of this form.' or other page continuation text).

Enter the page number text or label displayed in the bottom-center of the page (for example 'Page 1' or a numeric page identifier).

Enter the patient’s primary diagnosis and include the corresponding ICD‑9 or DSM code.

Enter the claimant’s insurance policy number as shown on their policy documents.

Enter the patient’s full name in the order First, Middle, Last.

Enter the day portion of the patient’s date of birth.

Enter the month portion of the patient’s date of birth.

Enter the year portion of the patient’s date of birth.

Enter the small section identifier or reference value shown for Section A (used for internal/form tracking).

Enter the policy or certificate number(s) associated with the claim as shown on the insurance documents.

Enter the full name of the claimant (person making the claim) exactly as it appears on file.

Enter or confirm the form title or header text shown at the top of this page.

Check this box when filling the day (DD) portion of the hospital confinement end/through date. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Enter the clock time the patient was admitted to the hospital. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Check this box when filling the month (MM) portion of the hospital confinement end/through date. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Check this box when filling the day (DD) portion of the hospital confinement start date. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Check this box when filling the month (MM) portion of the hospital confinement start date. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Enter the date when the patient’s hospital confinement ended. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Enter the date when the patient’s hospital confinement began. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Enter the clock time the patient was discharged from the hospital. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Enter the full name of the hospital where the patient was confined. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Enter the hospital’s street address, including number, street name and any suite or building information. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Enter the city in which the hospital is located. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Enter any additional ZIP or postal-code characters or related postal details for the hospital address.

Enter the hospital discharge date for this confinement.

Provide any additional city-related information or continuation of the city name if needed.

Enter the hospital ZIP code including the 4‑digit extension if available. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Enter the two‑letter state or province where the hospital is located. Fill only if 'Has the patient been hospital confined? — Yes' is 'Yes'.

Enter the hospital admission date for this confinement.

Check this box if the patient has not been confined to a hospital for the condition.

Check this box if the patient has been confined to a hospital for the condition.

Enter a brief statement about whether the patient was referred to a medical rehabilitation or therapy program and a concise summary of the referral (e.g., yes/no, referral reason). Fill only if 'Referred to medical rehabilitation or therapy program - Yes' is 'Yes'.

Provide full details of the rehabilitation or therapy referral such as program name, treating facility or therapist, anticipated start date, frequency/duration of treatment, and any other relevant notes. Fill only if 'Referred to medical rehabilitation or therapy program - Yes' is 'Yes'.

Check this box when the patient has been referred to a medical rehabilitation or therapy program.

Check this box when the patient has not been referred to a medical rehabilitation or therapy program.

List all medications the patient is currently taking and include the dose and how often each medication is taken.

Describe any other treatments (non-medication) the patient is receiving and specify the type, frequency, and any pertinent details for each treatment.

Enter the claimant's mental impairment class or short code (e.g., 'Class 1', 'Class 4' or a brief descriptive entry) to indicate the applicable classification.

Enter any supplementary details or clarifying notes about the mental impairment classification (for example severity modifiers, explanatory text, or other relevant remarks).

Check this box if the patient's mental impairment is classified as Class 1 (no limitation).

Check this box if the patient's mental impairment is classified as Class 5 (severe limitation).

Check this box if the patient's mental impairment is classified as Class 3 (moderate limitation).

Check this box if the patient's mental impairment is classified as Class 2 (slight limitation).

Check this box if the patient's mental impairment is classified as Class 4 (marked limitation).

Enter the details of any other consultations you have referred the patient for, including the type of consultation, reason, names of specialists or facilities, and relevant dates or notes. Fill only if 'Have you referred the patient for other types of consultations? — Yes' is 'Yes'.

Check this box when you have referred the patient for other types of medical consultations and want to indicate 'Yes'.

Check this box when you have not referred the patient for other types of medical consultations and want to indicate 'No'.

Enter the date the signature was provided.

Provide the signature of the physician.

Enter the Taxpayer Identification Number (TIN) or Social Security Number.

Enter 'Yes' or 'No' to indicate whether you believe the patient is competent to endorse checks and/or direct the use of proceeds. Fill only if 'Patient competent to endorse checks — No' is 'No'.

Check this box when you believe the patient is competent to endorse checks and direct the use of proceeds.

Check this box when you do not believe the patient is competent to endorse checks or direct the use of proceeds.

Enter the physician’s local fax number (the remaining digits after the area code).

Enter the three-digit area code for the physician’s fax number.

Enter the physician's professional degree or credentials (for example MD, DO, NP, PA) as printed on their medical license or professional registration.

Enter the attending physician's full name (last name, first name and middle initial as applicable) exactly as it should appear on the form.

Enter the physician's 3‑digit telephone area code for the phone number shown on the form.

Enter the physician's local telephone number (the remaining 7 digits, e.g., prefix and line number) as it appears on the form.

Enter the physician's medical specialty or board certification (for example, 'Cardiology', 'Family Medicine', or 'Psychiatry').

Enter the state for the physician’s address (use the two‑letter U.S. state abbreviation or full state name).

Enter the city for the physician's mailing address.

Enter the physician's street address including house/building number and suite or unit information if applicable.

Enter the physician's 5‑digit ZIP code and optional 4‑digit extension (ZIP+4), with or without a hyphen.

Provide a detailed description of any present complications or anticipated difficulties related to pregnancy, delivery, or the postpartum period (include what the problem is, onset/date(s), severity, and any relevant clinical details). Fill only if 'Post partum - Yes', 'Pregnancy - Yes', 'Delivery - Yes' is 'Yes' (any).

Check this box if there are present complications or anticipated difficulties related to the post partum period.

Check this box if there are present complications or anticipated difficulties in connection with the current pregnancy.

Check this box if there are no present complications or anticipated difficulties related to the post partum period.

Check this box if there are no present complications or anticipated difficulties in connection with the current pregnancy.

Check this box if there are present complications or anticipated difficulties in connection with delivery.

Check this box if there are no present complications or anticipated difficulties in connection with delivery.

Enter the day portion of the delivery date as a two-digit day of month (DD) for the pregnancy date in MM/DD/YYYY format (01–31).

Check this box to indicate/record the day (DD) portion of the patient’s date of delivery.

Check this box to indicate/record the month (MM) portion of the patient’s date of delivery.

Enter the delivery type that is expected or that occurred (for example: Vaginal, C-Section, or another specified delivery method). Fill only if 'This delivery is expected to be or was: C-Section' is 'Yes'.

Check this box if the delivery is expected to be, or already was, a cesarean (C-section) delivery.

Check this box if the delivery is expected to be, or already was, a vaginal delivery.

Enter the four-digit year of the expected due date (YYYY).

Enter the two-digit month of the expected due date (MM).

Check this box when completing the expected due date's month (MM) field of the pregnancy expected due date (MM/DD/YYYY).

Check this box to indicate or record the month (MM) portion of the patient’s first date of treatment for pregnancy.

The date the patient first began treatment related to this pregnancy.

Check this box to indicate or record the day (DD) portion of the patient’s first date of treatment for pregnancy.

Enter the date of the first day of the patient's last menstrual period.

Select this field when you are providing the month (MM) of the patient’s last menstrual period as part of the MM/DD/YYYY date.

Select this field when you are providing the day (DD) of the patient’s last menstrual period as part of the MM/DD/YYYY date.

Enter the referring physician's full street address for their office, including suite or unit number if applicable. Fill only if 'Was patient referred to you? Yes' is 'Yes'.

Enter the postal ZIP code for the referring physician's office, including the 4-digit extension if available. Fill only if 'Was patient referred to you? Yes' is 'Yes'.

Enter the city where the referring physician's office is located. Fill only if 'Was patient referred to you? Yes' is 'Yes'.

Enter the state where the referring physician's office is located (state abbreviation or full name). Fill only if 'Was patient referred to you? Yes' is 'Yes'.

Enter the full name of the referring physician (first, middle, last) who referred the patient. Fill only if 'Was patient referred to you? Yes' is 'Yes'.

Check this box if the patient was not referred to you (i.e., they came without a referral).

Check this box if the patient was referred to you by another physician or provider.

Enter the date the patient was or will be able to return to full-time work.

Check this box to indicate/record the month (MM) portion of the patient’s full-time return-to-work date in the MM/DD/YYYY field.

Check this box to indicate/record the day (DD) portion of the patient’s full-time return-to-work date in the MM/DD/YYYY field.

Enter the date the patient was or is expected to return to part-time work.

Check this box to indicate/record the day (DD) of the patient’s part-time return-to-work date.

Check this box to indicate/record the month (MM) of the patient’s part-time return-to-work date.

Enter the date the patient was or is expected to return to part-time work.

Check this box if the patient's condition prevents them from being able to perform self-care.

If you answered No to the self-care prevention question, check this box when you expect fundamental changes in the patient's medical condition within 1–2 months. Fill only if 'Prevents self-care — No' is 'No'.

If you answered No to the self-care prevention question, check this box when you expect fundamental changes in the patient's medical condition in 6 months or longer. Fill only if 'Prevents self-care — No' is 'No'.

Check this box if the patient's condition does not prevent them from performing self-care (if No, complete the expected change timeline below).

If you answered No to the self-care prevention question, check this box when you expect fundamental changes in the patient's medical condition within 5–6 months. Fill only if 'Prevents self-care — No' is 'No'.

If you answered No to the self-care prevention question, check this box when you expect fundamental changes in the patient's medical condition within 3–4 months. Fill only if 'Prevents self-care — No' is 'No'.

Enter the date(s), name(s) of the surgical procedure(s) the patient has undergone and the outcome/result for each surgery. Fill only if 'Has the patient undergone surgery? — Yes' is 'Yes'.

Check this box if the patient has previously undergone surgery (and provide the date, procedure and result in the space provided).

Check this box if the patient has not undergone any surgery.

Describe the objective clinical findings observed on examination or testing that support the diagnosis, including relevant signs, test results, measurements, or imaging findings.

List the patient's current symptoms related to the condition, including onset, severity, frequency, location, and any factors that exacerbate or relieve them.

If there are secondary or comorbid conditions that contribute to the patient's inability to work, list each condition and briefly explain how it contributes; if none, enter 'None.' Fill only if 'Secondary conditions contributing to inability to work — Yes' is 'Yes'.

Check this box if there are secondary conditions that contribute to the patient’s inability to work.

Check this box if there are no secondary conditions contributing to the patient’s inability to work.

Enter the date when the patient's symptoms first appeared.

Enter the date of the patient's most recent visit with you.

Enter the date of the patient's first visit for this condition.

Describe how often you treat or consult with the patient (for example, 'weekly', 'monthly', 'as needed').

Enter the date you believe the patient was first unable to work due to the condition.

Enter the state for the referring physician's address (typically the two-letter state abbreviation).

Enter a short, plain‑language description of the patient’s work activities or tasks they are unable to perform because of their medical condition.

Enter a brief description of the specific work tasks, activities or duties the patient should NOT perform because of their medical condition.

If the patient's condition is work-related, briefly describe how the condition is related to the patient's job (include relevant work duties, exposures, events or mechanisms of injury, approximate dates or timeframes, and any other details that explain the relationship); if not work-related, enter 'Not work-related' or a brief explanation. Fill only if 'Work-related Condition — Yes' is 'Yes'.

Check this box if the patient's condition is work‑related (the condition arose out of or is directly related to the patient's job or workplace activities).

Check this box if the patient's condition is not work‑related (the condition did not arise out of or is not related to the patient's job or workplace activities).