What the INS-2944B is for
Disability Credit Protect is optional coverage added to a new Empire Life life insurance policy. If the insured can’t work because of a disability, it pays a monthly benefit toward their mortgage, rent or other monthly credit obligations, for up to 12 or 24 months depending on the plan. The INS-2944B package holds the claimant’s statement and the attending physician’s statement. Proof of the eligible debts goes on a separate form, INS-2944A. It’s easily confused with lender-sold creditor insurance, such as Canada Life balance protection, which is a different product with its own forms.
Who completes it
The life insured completes Sections 1 to 7 of the claimant’s statement, and the policy owner completes Sections 8 and 9 and signs the declaration. The life insured also completes Section 1 of the attending physician’s statement, which authorizes you to release medical information. The treating specialist or family physician completes Sections 2 to 13.
The package is seven pages, so the claimant usually fills in the claimant’s statement at home, signs Section 1 of the physician’s statement, and brings the pages to the clinic. In Medulla, you can send those parts to the patient over a secure link before the visit. They answer on the form and their responses land on the PDF you complete Sections 2 to 13 on, so the package arrives complete. Empire Life still asks for original signatures on the physician’s statement.
How to fill in the attending physician’s statement
Diagnosis and history
Record height, weight, your last visit, whether you’re the family physician and how long you’ve treated the patient. Give the primary and secondary diagnoses and associated conditions that may prolong recovery. In history, cover tobacco use, whether an accident or the patient’s work caused the condition, onset and first visit dates, the date they stopped work, prior similar conditions and any licence restricted because of it.
Symptoms and treatment
Describe subjective symptoms and severity, objective findings and significant results, any bed, house or hospital confinement, and pregnancy. List current treatment, whether the patient follows it or has refused any, pending surgery or tests, and other physicians involved.
Prognosis and return to work plan
State whether the patient has recovered, improved, stayed the same or deteriorated, your prognosis, whether they’ve reached maximal medical improvement and when you expect change. Say whether medical or vocational rehabilitation fits. If they were employed at onset, describe the return-to-work plan: part time, modified or regular, with dates.
Impairment sections
Complete only the sections that apply. For physical impairment, choose a functional class from 1 to 5 and the lifting and movement limits. For cardiac impairment, give the last blood pressure and the American Heart Association functional class. For psychological impairment, describe symptoms, effect on work, home and workplace factors, psychiatric referral and DSM diagnosis, and competence to manage the proceeds. For visual impairment, record acuity and whether it can be restored.
Comments and signature
Add comments, then your name, specialty, address, phone, fax, signature and date.
Common reasons it’s delayed
- Impairment sections left blank where they apply, or classes chosen without limits described.
- No prognosis or timing for change in the patient’s condition.
- A return-to-work plan missing for a patient who was employed at onset.
- The Section 1 authorization unsigned.
- A copy sent where Empire Life needs the original signature.
Submitting and who pays
The claimant returns the package to Empire Life Retail Claims at 259 King St East, Kingston, by mail, by fax to 1 800 419-4051, or by email to individualclaims@empire.ca. Empire Life may ask for more information before deciding. The life insured pays your fee for the statement, so clinics bill the patient directly.