Insured employees and plan members

To make an extended health care dental claim and/or disability claim, 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
441 Application for Coverage for Dependent Child over 21 Administration Forms
564 Application For Long Term Disability Benefits - Employee Disability Claims
185QA Attending Physician's Statement Cancer Disability Claims
187QA Attending Physician's Statement Cardiac Disability Claims
563 Attending Physician's Statement Disability Benefits Underwriting
Disability Claims
188QA Attending Physician's Statement General Disability Claims
184QA Attending Physician's Statement Musculoskeletal Disability Claims
186QA Attending Physician's Statement Psychiatric Disability Claims
190 Authorization for Direct Deposit Administration Forms
210B Claim For Accidental Dismemberment Benefit Disability Claims
573 Coverage2go Application Administration Forms
Group Admin
Marketing Materials
520 Dental Claim Form Health and Dental
684B Foreign Death Claim Disability Claims
209 Group Dependent Life Claim - Statement of Employer Disability Claims
210 Group Life & Dependent Life Claim - Statement of Employer Disability Claims
1781 Group Life & Disability Claims Guide Disability Claims
684 Group Life Claim - Claimant’s Statement Disability Claims
529 Group Life Insurance Waiver Of Premium Application - Employee Form - Ongoing Eligibility Review Disability Claims
523A Group Life Insurance Waiver of Premium Application - Employee Information Disability Claims
523B Group Life Insurance Waiver of Premium Application - Employer Form Disability Claims
438 Group Plan Member Change Form Administration Forms
522 Group Web Administration Guide Administration Forms
Group Admin
197 Job Description – Employer Form Disability Claims
238 Long Term Disability Employer Statement Disability Claims
1774 Medical Cannabis Reimbursement Request Claims
Health and Dental
195 myFlex Benefits New Plan Member Application Administration Forms
1552 myFlex Benefits Plan Member Change Form Administration Forms
191ML 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
456 Plan Member Group Life and AD&D Insurance Beneficiary Designation Administration Forms
205 Pre-Authorized Debit For Group Insurance Premium Administration Forms
683 Proof of Death - Physician's Statement Disability Claims
567 QuickAssess Absence And Accommodation Review Service - Employer Referral Form Disability Claims
1876 Request for brand name drug Claims
Health and Dental
421 Short Term Disability Claim Form Disability Claims
421B Short term disability employer COVID-19 claim form Disability Claims
421A Short term disability plan member COVID-19 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
420 Status On Return Of Absent Employee Disability Claims
466 Supplementary Health Benefits Claim Form Health and Dental
422 Supplementary Report on Claim for Disability Benefits Disability Claims
948 Vision Care Form Health and Dental