Insured employees and plan members

To make an extended health care dental claim and/or disability dlaim, you may print, complete and submit the appropriate form to Equitable Life. If your plan requires your group plan administrator to provide an authorizing signature, be sure to obtain the signature before submitting your claim.

Benefits are adjudicated based on the details provided on your claims forms. Incorrect or incomplete information may result in denial or improper payment of your claims.

No. Name
1425 Actemra (tocilizumab) SDMP
441 Application for Coverage for Dependent Child over 21 Administration Forms
564 Application for Long Term Disability & Job Profile Disability Claims
563 Attending Physician's Disability Benefits Statement Disability Claims
185 Attending Physician's Statement - Cancer Disability Claims
187 Attending Physician's Statement - Cardiac Disability Claims
188 Attending Physician's Statement - General Disability Claims
184 Attending Physician's Statement - Musculoskeletal Disability Claims
186 Attending Physician's Statement - Psychiatric Disability Claims
190 Authorization for Direct Deposit Administration Forms
513A Booklet Reorder Form Administration Forms
573 Coverage2go Application Administration Forms
Other
Group Admin
Marketing Materials
520 Dental Claim Form Health and Dental
181 Employee's Guide - How to Submit a Long Term Disability Claim Disability Claims
197 Employer Job Description Administration Forms
Disability Claims
180 Employer's Guide on How to Assist an Employee Applying for Long Term Disability Benefits Disability Claims
209 Group Dependent Life Claim - Statement of Employer Administration Forms
Disability Claims
684 Group Life Claim Claimant's Statement Disability Claims
210 Group Life Claim Statement of Employer Administration Forms
Disability Claims
529 Group Life Insurance Waiver of Premium - Ongoing Eligibility Review Disability Claims
523A Group Life Insurance Waiver of Premium Application - Employee Disability Claims
523B Group Life Insurance Waiver of Premium Application - Employer Administration Forms
Disability Claims
438 Group Plan Member Change Form Administration Forms
238 Long Term Disability Employer Statement Disability Claims
191 New Plan Member Group Insurance Application Administration Forms
427 Ongoing Long Term Disability Update Disability Claims
509 Optional Life Insurance Application and Statement of Health Administration Forms
466PD Pay Direct Drug Claim Form Health and Dental
456 Plan Member Group Life and AD&D Insurance Beneficiary Designation Administration Forms
200 Plan Sponsor's Report On New Plan Members, Changes and Terminations Administration Forms
683 Proof of Death - Physician's Statement Administration Forms
Disability Claims
567 QuickAssess Employer Referral Form Disability Claims
420 Return of Absent Employee Form Disability Claims
421 Short Term Disability Claim Form Disability Claims
425 Short Term to Long Term Disability Application - Employee Disability Claims
426 Short Term To Long Term Disability Application - Employer Disability Claims
452 Statement of Health for Group Insurance Administration Forms
466 Supplementary Health Benefits Claim Form Health and Dental
422 Supplementary Report on Claim for Disability Benefits Disability Claims
948 Vision Care Form Administration Forms
Health and Dental