Customer Administration Forms

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CUSTOMER ADMINISTRATION FORMS

Enrollment Instructions | Enrollment Forms | Claim Forms | Administration Forms

Enrollment Instructions

Life and Disability

Evidence of Insurability Instructions

Dental and Vision

Enrollment Forms

Life

• Enrollment Form
• Beneficiary Designation Form
• Evidence of Insurability Form

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

• Vision Enrollment Form

Claim Forms

Claim Submission Information - Equitable Life and Disability

Claim Submission Information - DBL and PFL

Life and W-9

Life Waiver of Premium

Accelerated Death Benefit

STD Telephonic Intake

STD

LTD

Dental

Vision

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

• COBRA
• ID Cards
• Privacy

Vision

• COBRA
• ID Cards
• Privacy