D.A. Townley.  -  Plan Administrators      



Long Term Disability Claim - Attending Physician's Statement

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.

You must complete the patient's section of the form 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.

Plan Administrator
Millworkers Health & Welfare Plan (Unifor) Administrator
c/o D.A. Townley
160 – 4400 Dominion Street
Burnaby, BC V5G 4G3

Phone: 604-299-7482 or 1-800-663-1356
Fax: 604-299-8136

Email: Health

Form Link

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