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Disability Attending Physician's Statement - Aetna

GC-485-4 (3-02) A-POD Page 1 of 2 Disability Attending Physician's Statement Complete this form in full. The patient is responsible for completion of this form without expense to the company. You may use the Remarks section on the reverse side if you need more room to respond. If you have any questions, please call (800) 726-7777. Employer Information Name Type of Claim LTD Waiver of Premium LTD/PTD Patient Information Name Social Security Number Birthdate (MM/DD/YYYY) Address (include No. Street, Town, State, Zip Code) Address is new 1. History (a) Height Weight (b) Date symptoms first appeared or accident happened .. Mo. Day Yr. (c) Date patient ceased work because of Disability .

GC-485-4 (3-02) A-POD Page 1 of 2 Disability Attending Physician's Statement Complete this form in full. • The patient is responsible for completion of this form without

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