Important: only complete this form if you are an authorized representative. If the applicant can sign the form himself/herself, the doctor’s form is not required.
If claimant is unable to sign Claims Conference documentation, such as an application form or a life certificate, an authorized representative may sign on his/her behalf. The authorized representatives must submit ALL of the following documents to the Claims Conference:
Please note: the doctor must have seen the claimant within the past two months in order for this form to be accepted by the Claims Conference.