Group Benefit Forms

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.

Form No. Form Name Category
180 Employer's Guide on How to Assist an Employee Applying for Long Term Disability Benefits Disability Claims 
181 Employee's Guide - How to Submit a Long Term Disability Claim Disability Claims 
184 Attending Physician's Statement - Musculoskeletal Disability Claims 
185 Attending Physician's Statement - Cancer Disability Claims 
186 Attending Physician's Statement - Psychiatric Disability Claims 
187 Attending Physician's Statement - Cardiac Disability Claims 
188 Attending Physician's Statement - General Disability Claims 
190 Authorization for Direct Deposit Administration Forms 
191 New Plan Member Group Insurance Application Administration Forms 
197 Employer Job Description Administration Forms
Disability Claims 
200 Plan Sponsor's Report On New Plan Members, Changes and Terminations Administration Forms 
209 Group Dependent Life Claim - Statement of Employer Administration Forms
Disability Claims 
210 Group Life Claim Statement of Employer Administration Forms
Disability Claims 
238 Long Term Disability Employer Statement Disability Claims 
420 Return of Absent Employee Form Disability Claims 
421 Short Term Disability Claim Form Disability Claims 
422 Supplementary Report on Claim for Disability Benefits Disability Claims 
425 Short Term to Long Term Disability Application - Employee Disability Claims 
426 Short Term To Long Term Disability Application - Employer Disability Claims 
427 Ongoing Long Term Disability Update Disability Claims 
438 Group Plan Member Change Form Administration Forms 
441 Application for Coverage for Dependent Child over 21 Administration Forms 
452 Statement of Health for Group Insurance Administration Forms 
466 Supplementary Health Benefits Claim Form Health and Dental 
466PD Pay Direct Drug Claim Form Health and Dental 
513A Booklet Reorder Form Administration Forms 
520 Dental Claim Form Health and Dental 
523A Group Life Insurance Waiver of Premium Application - Employee Disability Claims 
523B Group Life Insurance Waiver of Premium Application - Employer Administration Forms
Disability Claims 
529 Group Life Insurance Waiver of Premium - Ongoing Eligibility Review Disability Claims 
563 Attending Physician's Statement (ongoing) Administration Forms
Disability Claims 
564 Application for Long Term Disability & Job Profile Disability Claims 
567 QuickAssess Employer Referral Form Disability Claims 
683 Proof of Death - Physician's Statement Administration Forms
Disability Claims 
684 Group Life Claim Claimant's Statement Disability Claims 
750 Application for Plan Member Optional and Spousal Optional Life Benefit Administration Forms 
750C Change Form for Plan Member and Spousal Optional Life Benefit Administration Forms 
948  Vision Care Form Administration Forms
Health and Dental