During the COVID-19 situation, we encourage you to submit your employee statement, consent form and attending physician’s statement online.
Don’t fill the forms out in your browser. The information will appear on your screen but won’t be captured when you submit the forms. Save a copy of the form to your computer or device before filling it out. Complete the required forms and save them as PDFs. If you can’t sign the forms, leave the signature blank for now.
Select Submit online to upload your first document. Then select Submit another document to upload the second and repeat to upload the third.
You can also fax the information or request secure email. For this info, please refer to your local disability management services office.
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.
During the COVID-19 situation, we encourage you to submit this form online. Or you can fax it to the Great-West Life Disability Management Services Office nearest to where you live.
Attending physician’s statement
Choose the statement that applies to you. Have your doctor complete and sign the form. During the COVID-19 situation, we encourage you to submit this form online. Or you can fax it to the Great-West Life Disability Management Services Office nearest to where you live.
Cancer conditions - 152 kbpdf Opens in a new window
Cardiac conditions - these types of illnesses are also referred to as heart conditions. - 179 kbpdf Opens in a new window
Mental health conditions - 364 kbpdf Opens in a new window
Musculo-skeletal conditions - these conditions affect the functioning of your joints, tendons, ligaments and muscles. - 311 kbpdf Opens in a new window
Long term disability other conditions - this form can be used for all other medical conditions. - 387 kbpdf Opens in a new window
Short term disability and early referral services - this form can be used for all other medical conditions. - 204 kbpdf Opens in a new window
Print all condition forms - this PDF includes all of the condition forms. - 924 kbpdf Opens in a new window
Note: Any fees charged by your physician relating to the completion of claim reports including this Attending Physician’s Statement are your responsibility.
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. After you’ve submitted it, select Submit another document to upload your consent form and the attending physician’s statement.
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.