HTML version of the form: Claim for Disability Insurance Employee's Medical Information and Attending Physician's Statement Policy No. 12500-G (TBS/SCT 330-304)

For the Employee

To avoid delay, you must fully complete and sign Part 1 of this form, and have your doctor complete Part 2. Please keep Part 1 attached to Part 2. Your doctor should send this completed form to Sun Life Assurance Company of Canada (referred to in this form as the "Insurer"), at the address provided at the end of this form. You are responsible for the cost of completing this form.

PART 1: EMPLOYEE INFORMATION

About you

• Last Name:
• Given Name:
• Maiden Name (for Quebec residents):
• Street Address:
• Home Telephone No.:
• City:
• Province:
• Postal Code:
• Date of Birth ( Day / Month / Year ):
• Sex
  • Male
  • Female
    • Ms.
    • Mrs.
    • Miss
• Certificate No. CG-:

About your illness or injury

1. Please describe your present illness or injury and how it prevents you from working. Include a description of the duties of your job that you are unable to perform because of your illness or injury. (Attach extra sheets, if necessary.):
2. When did your symptoms first appear?
   • Day:
   • Month:
   • Year:
3. Have you ever had the same symptoms or a similar illness or injury?
   • No
   • Yes

   If yes, please explain and give dates.:

4. On what date did you first see a doctor for this illness or injury?
   • Day:
   • Month:
   • Year:
5. On what date did you become totally unable to perform the duties of your own occupation?
   • Day:
   • Month:
   • Year:
6. Have you had to change your daily activities because of your illness?
   • No
   • Yes

   If yes, please describe your daily activities before you became ill and your daily activities now. (Attach extra sheets, if necessary.)

   Activities before you became ill:

   Activities now:

7. What treatment(s) are you currently receiving (medicine, diets, advice from a doctor, physiotherapy, psychotherapy, etc.)?
8. Do you have a valid driver’s licence?
   • No
   • Yes

   If your driving has been restricted as a result of your illness or injury, please give details. Please also explain how you get around when you leave your house (i.e. drive, public transport, taxi, etc.).

9. Provide the names and addresses of all the doctors you consulted during your present illness or injury.

   Name of doctor	Address	Date of visit

Your general medical history Attach extra sheets, if necessary.

1. List all the doctors you have consulted during the past five years.

   Name of doctor	Address	Nature of illness / injury	Treatment prescribed (medicine, diet, etc.)	Date of visit / treatment

2. Please list the names and addresses of all the hospitals where you received treatment during the past five years, including any type of surgery.

   Nature of illness / injury	Date of visit or confinement	Treatment or surgery (medicine, diet, etc.)	Name and address of hospital
   If, as a result of any of these prior illnesses or injuries, changes in activities or work restrictions were advised, please describe what the changes were:

Employee’s declaration, authorization and signature

• I certify that the statements on this form are true and complete.
• I authorize my doctor, Sun Life Assurance Company of Canada and any person or organization who has relevant personal information about me, including health professionals and institutions, investigation agencies, insurers and persons performing services for Sun Life Assurance Company of Canada, to exchange information needed for underwriting, administration or paying claims.
• I agree to a personal investigation in connection with this claim.
• I agree that a photocopy of this authorization is as valid as the original.

• Employee’s Signature:
• Date:

PART 2: ATTENDING PHYSICIAN’S STATEMENT

Medical History

Please fill in this form completely and as soon as possible to ensure that there is no delay of any payments to which the employee may be entitled. Sun Life Assurance Company of Canada (referred to in this form as the "Insurer"), will use the information on this form to determine the employee’s eligibility for disability benefits. Your accurate and detailed completion of this form will help the Insurer to arrive at a just decision. The Insurer may request up-to-date medical or fitness information from you to review the employee’s progress and potential to return to work. The employee is responsible for the cost of completing this form.

1. What was the date of the patient’s first appointment for this illness or injury?
   • Day:
   • Month:
   • Year:
2. What was the date of the patient’s latest appointment?
   • Day:
   • Month:
   • Year:
3. Did you recommend that the patient stop work?
   • No
   • Yes

   If yes, as of what date?

   • Day:
   • Month:
   • Year:
4. How often are the patient’s appointments?
   • Weekly
   • Bi-weekly
   • Monthly
   • Other (Please specify.):
5. Was the patient’s illness or injury caused by an accident?
   • No
   • Yes

   If yes, please give the details and the date of the accident.

6. Describe the pertinent symptoms, their severity, their duration and their impact on the claimed disability (including the patient’s ability to work).
7. When did the symptoms first appear?
   • Day:
   • Month:
   • Year:
8. Has the patient ever had a similar or related condition?
   • No
   • Yes

   If yes, state when and describe the condition.

9. Is the condition due to injury or illness caused by employment?
   • No
   • Yes
   • Unknown

   If yes, give details.

10. Is the condition due to or related to pregnancy?
    • No
    • Yes

    If yes, give dates of confinement.

    From

    • Day
    • Month
    • Year

    to

    • Day
    • Month
    • Year
11. How is the patient restricted or limited by the condition?
12. What is the patient’s current status?
    • Ambulatory
    • House confined
    • Using a walking aid
    • Using a wheelchair
    • Bed confined
    • Hospital confined
13. Please indicate the patient’s current height and weight.
    • Height:
    • Weight:

Clinical findings

Please describe the physical findings in relation to the illness or injury.

Diagnoses

What are the diagnoses that have led to the disability claim? Please list them in order of their importance to the patient’s illness or injury and their impact on the claimant. If the condition is psychiatric, use DSM IV terminology.

Investigations

What procedures and examinations were done? Please include copies of the reports of X-rays, ECGs, laboratory data and all other investigations related to the illness or injury. (Attach available consultation notes.)

Treatment

1. Was this patient hospitalized?
   • No
   • Yes

   If yes, give dates:

   From

   • Day
   • Month
   • Year

   to

   • Day
   • Month
   • Year
2. Was surgery performed or is it scheduled?
   • No
   • Yes

   If yes, give details:

   Date	Type of Surgery

3. What medications were prescribed to the patient? Please include names, dates first prescribed, dosage and the dates of any medication changes.
4. Has the patient been given counselling or psychotherapy?
   • No
   • Yes

   If yes, give frequency and duration.(Attach copies of reports.)

5. Has the patient received physiotherapy/chiropractic treatment?
   • No
   • Yes

   If yes, give frequency and duration.(Attach copies of reports.)

6. What other treatments have been or are being given?
7. Please describe the result of all treatments to date.
8. To what extent has the patient complied with the treatment plan? Please explain any factors that may have prevented compliance.
9. Please give names, specialties and appointment dates of any consulting physicians or health care professionals such as psychologists.(Attach copies of consultation notes.)

   Name and Address	Specialty	Appointment date

Cardiac  Complete if applicable.

1. What is the functional capacity (American Heart Association)? If Class 3 or 4, please include a copy of stress test or cardiac echogram.
   • Class 1 (no limitation)
   • Class 3 (marked limitation)
   • Class 2 (slight limitation)
   • Class 4 (complete limitation)
2. What is the latest blood pressure reading for the patient?
3. Date blood pressure reading recorded:
   • Day
   • Month
   • Year

Vocational rehabilitation and return to work information

1. Which of the following best describes the progress of the patient’s condition since the patient stopped working?
   • Recovered
   • Improved
   • Unchanged
   • Regressed
2. Please describe the patient’s functional restrictions (physical or psychological), if any.
3. Over what period of time can recovery of usual functional abilities be anticipated?
   • 1-3 months
   • 4-6 months
   • 7-9 months
   • over 9 months
4. If a specific date of recovery for work is anticipated, please indicate it.
   • Day
   • Month
   • Year
5. Have you scheduled a reassessment for this patient?
   • No
   • Yes

   If yes, give date.

   • Day
   • Month
   • Year
6. Do you foresee this patient as a potential candidate for vocational rehabilitation:
   • Now:
     • No
     • Yes
   • Future:
     • No
     • Yes

     If yes, please explain:

7. Please describe any other factors that may affect this patient’s ability to return to work.
8. Please comment on the patient’s willingness to return to work.

Additional information

1. In your opinion, does the patient have any physical or mental limitations that would prevent him/her from handling his or her own financial affairs?
   • No
   • Yes

   If yes, give details of any physical or mental limitations.

2. Would further communication with the Insurer’s Medical Director be beneficial?
   • No
   • Yes
3. Would it be helpful for you to speak with a Rehabilitation Specialist representing the Insurer?
   • No
   • Yes

Physician information

• Name (Please print.):
• Street Address:
• City:
• Province:
• Postal Code:
• Specialty:
• Telephone No.:
• Fax No.:

Physician Signature

• Signature:
• Date:

To keep this document confidential, please send this form to the Sun Life Assurance Company of Canada Claims Office listed below:

Montreal Group Disability Management Office
Federal Government Disability Insurance Plan
PO Box 12500 Stn CV
Montreal, QC H3C 5T6

Provision of the information requested in this form is voluntary. The information is being collected by the Insurer for the purpose of the administration and the assessment of claims under the Disability Insurance Plan. This information is essential to the Insurer’s decision concerning this claim. Refusal to respond fully may result in disability benefits not being approved. All information provided is strictly confidential, for use by the Insurer, in connection with the Disability Insurance Plan.

TBS/SCT 330-304E (2001-06-04)