Group Critical Illness Claim Form (Page 3 of 3) in pdf

ATTENDING PHYSICIAN’S STATEMENT

Patient’s Name:

Age:

Diagnosis:

If condition is due to pregnancy, what is expected delivery date? Date

MO/DAY/YR

When did symptoms first appear or accident happen? Date

MO/DAY/YR

When did patient first consult you for this condition? Date

MO/DAY/YR

Has patient ever had same or similar condition? (If “yes,” state when and describe.)

 Yes

 No

Describe any other diseases or infirmity affecting present condition.

Nature of surgical or obstetrical procedure, if any (describe fully).

Is patient unable to perform job duties?

 Yes

 No If yes, from

through

9a. What specific job duties is patient unable to perform?

9b. Specific RESTRICTIONS (What the patient should not do and why). Please quantify in hours, weight, etc.

9c. Specific LIMITATIONS (What the patient cannot do and why).

10. If retired or unemployed which activities of daily living (ADLs) is patient unable to perform?

11. Date patient last examined by you:

Frequency of visits:  weekly  monthly  other

12. Is patient:  ambulatory

 bed confined

 house confined

 other

13. If patient is hospitalized, give name and address of hospital.

Hospital:

City:

Province:

14a. Date admitted:

Date discharged:

MO/DAY/YR

14b. When do you expect patient to resume partial duties?

Full duties?

MO/DAY/YR

14c. If patient is unemployed or retired, on what date would you expect a person of like age, gender and good health to resume his/her normal and

necessary activities?

MO/DAY/YR

15. Have you completed paperwork for any other insurance company?  Yes

 No

Remember, it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important. Check to

be sure that all information is correct before signing.

PHYSICIAN VERIFICATION

Signed:

, MD

Date:

Phone: (

)

MO/DAY/YR

Street Address:

City/Town:

State/Province:

Postal Code:

Important: To avoid delay, please sign authorization below.

I authorize any physician, medical practitioner, hospital, clinic or other medical facility, insurance company, provincial health insurance plan, government

department or agency or other organization, institution or person, that has records or knowledge of me or my health to give to Allstate Insurance

Company of Canada (AICC), their respective authorized plan administrators, representatives and/or producers any information relating to my claim. A

copy of this authorization is as valid as the original. This authorization applies to any dependent on whom a claim is filed, and I confirm that I am

authorized to act on behalf of my dependent. This authorization shall remain valid for as long as I am claiming benefits, or until revoked in writing by

myself. I or my representative may receive a copy of this authorization by supplying certificate number(s) and Insured’s name in a written request to the

company.

Sign here

Date:__________________



Check here if address is new

Claimant

Mailing Address:

City:

Province:

Postal Code:

Telephone No:.

AICC10365