D.A. Townley  -  Plan Administrators Iron Workers Union Local 97 International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers 
 

health
benefits

        
 
 
 
 
 
 
 
 
 
 
 
 
   
        
   
 
 
 
 
   
 
 
 
 
   
 

Long Term Disability - Attending Physician's Statement

Use
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 also complete the patient's section of the Attending Physician's Initial LTD Benefits Statement 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.



 

Form Link
 

Related Links
Statement of Claimant for Long Term Disability Benefits
Statement of Employer Regarding Employee Group Long Term Disability Claim
Application for Disability Credits
 
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