Long Term Disability Claim – Attending Physician’s Statement

Once you have applied for LTD Benefits, you may be required to complete the Attending Physician’s Initial LTD Benefits Statement before your LTD claim can be approved.

Information Needed to Complete the Form
Your name and signature is needed to complete the form. In addition, your doctor must provide detailed medical information related to your current condition and sign the form.

Please follow the instructions on the form.

Notes
You must complete the patient’s section of the form before forwarding to your doctor for completion.

Questions on completing the form should be directed to the Plan Administrator.

Completed forms should be mailed directly to the insurer.

Plan Administration Office

45 McIntosh Drive
Markham, ON L3R 8C7

Phone 1-800-263-3564
Fax 905-946-9700
Email: questions@millworkersuniforbenefits.org