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020-3485-STD-LTD-04-18
Attending Physician’s Statement
Disability Claim
Purpose of Statement
This Statement is to assist Sun Life Assurance Company of Canada ("Sun Life") in making a decision on your patient’s claim for disability benefits.
The term "claim" as used throughout this statement relates to the assessment of the plan member's absence from work under the Short-Term
Disability (STD) plan and where applicable, the member's absence from work under the Long-Term Disability (LTD) plan.
Return address
Return this Statement to your patient or fax it to the confidential fax number that appears below for the appropriate Sun Life Disability
Management office. Please confirm the appropriate Disability Management office with your patient. You do not need to mail information
that you fax. Please retain the original copy for your records.
Edmonton:
Fax: 1-866-639-7820
PO Box 2733 Stn Main
Edmonton AB T5J 5C9
Toronto:
Fax: 1-866-639-7851
PO Box 950 Stn A
Toronto ON M5W 1G5
Halifax:
Fax: 1-866-639-7850
PO Box 11480 Stn CV
Montreal QC H3C 5P5
Montreal:
Fax: 1-866-639-7846
PO Box 11037 Stn CV
Montreal QC H3C 4W8
Kitchener - Waterloo:
Fax: 1-866-209-7215
PO Box 100 Stn C
Kitchener ON N2G 3W9
Vancouver:
Fax: 1-866-639-7829
PO Box 48810 Stn Bentall
Vancouver BC V7X 1A6
1 Plan Member information and authorization to be completed by patient
Last name First name Home telephone number Alternate telephone number
Address (street number and name) Apartment or suite
City Province Postal code
Plan Sponsor name Contract number Member ID number
Height Weight Date of birth (dd-mm-yyyy) Last date worked (dd-mm-yyyy) Date returned to work or expected return to work date
(dd-mm-yyyy)
I authorize my doctor to collect, use and disclose my personal information to Sun Life, its agents and service providers for the
purposes of underwriting, administration and adjudicating claims under this Plan. I agree that this authorization is valid
throughout the duration of my claim or during the resolution of any decision relating to my claim that I have disputed, but
for the purposes of audit, for the duration of the Plan. I agree that a photocopy of this authorization or electronic version is
as valid as the original.
Member’s signature
X
Date (dd-mm-yyyy)
2 Attending Physician’s Statement
Note to Physician – If your patient has returned to work or will return to work within 4 weeks of the Last Date Worked, complete
Section 2 only AND SIGN THE ATTENDING PHYSICIAN’S ACKNOWLEDGEMENT AT THE END OF THIS FORM. For absences
expected to be greater than 4 weeks, please complete all sections in full.
Diagnosis
Primary:
Secondary:
If childbirth: expected or actual delivery date (dd-mm-yyyy)
Vaginal
C-Section
Occupational illness/injury Is condition arising from employment?
Yes No
Start dates of current work absence
Date of first visit during current period of absence (dd-mm-yyyy)
First date of work absence due to condition (dd-mm-yyyy)
