Apply for short or long-term disability benefits or early referral services

Step 1

Your consent

We need your permission to obtain information necessary to help us assess your claim. By signing this authorization request, you give Great-West Life permission to obtain information from your doctor, employer, other insurers and hospitals where you received treatment.

Print, read, complete and sign this form, then fax or mail it to the appropriate Disability Management Services Office. If you’re not sure which Disability Management Services Office to send your claim to, contact your plan administrator.

Step 2

Attending physician’s statement

Print the statement that applies to you. Have your doctor complete and sign the form, and then fax or mail it to the appropriate Great-West Life Disability Management Services Office.

Note: Any fees charged by your physician relating to the completion of claim reports including this Attending Physician’s Statement are your responsibility.

Step 3

Employee statement

If you aren’t able to complete the entire form now, you can save it and finish it later. When the form is complete, save the final version and return here to submit it.

Submit online

If you have any questions about submitting your document online, contact us at 1-855-755-6729

Prefer to send us a printed copy?

Print the completed Employee’s Statement and then fax or mail it to the appropriate Disability Management Services Office.