CUSTOMER ADMINISTRATION FORMS
Enrollment Instructions | Enrollment Forms | Claim Forms | Administration Forms
Enrollment Forms
Life
Disability
- Short Term Disability Enrollment Form
- Long Term Disability Enrollment Form
- Evidence of Insurability Form
Dental
- 2 Tier Basic Plan | 2 Tier High Plan
- 3 Tier Basic Plan | 3 Tier High Plan
- 4 Tier Basic Plan | 4 Tier High Plan
Vision
Claim Forms
Claim Submission Information - Equitable Life and Disability
Claim Submission Information - DBL and PFL
Customers with both DBL and STD
For customers that have both STD and DBL coverages through The Business Council, please submit the AXA STD claim form to both Maxon(DBL) and AXA(GRP). Your e-mail notification should include both vendors so that each can coordinate their claim efforts.
- Maxon (DBL claim paying vendor)
Email Address: [email protected]
Fax: (845) 985-2249
- GRP (STD claim paying vendor)
E-mail Address: [email protected]
Fax: (855) 864-0530
STD
DBL/PFL
- Helpful Hints for Filing a Disability or PFL Claim
- Equitable DBL EE Statement
- Equitable DBL ER Statement
- PFL-Care for Family
- PFL-Bonding
- PFL-Military
- PFL-Covid-19 Self
- PFL-Covid-19 Child
- PFL – 2020 NYS Mandate to Reporting Requirements
- DBL - Evidence of Insurability
Administration Forms
Life
- Basic & Supplemental Life Portability
- Supplemental Life Portability
- Beneficiary Designation
- Beneficiary Change
- Conversion
- Portability and Conversion Flyer
Dental
Vision
Insurance Fund Contact
12 Corporate Woods Blvd.,
Suite 17 Albany, New York
12211-2390
T: 518.465.1571
F: 518.432.7033
[email protected]
Customer Administration Forms
Quick & Easy Reporting
The HR Line
T: 800.332.2117