Customer Administration Forms

---

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 Perfect
• Vision Eye Med/VSP

Claim Forms

Claim Submission Information - Equitable Life and Disability

Life and W-9

Life Waiver of Premium

Accelerated Death Benefit

STD Telephonic Intake

STD

LTD

Dental

Vision

Accident

Specified Disease

Wellness 

Acc, HI & Sp. Disease WOP Claim Form

Hospital Indemnity

DBL/PFL

• Helpful Hints for Filing a Disability or PFL Claim
• PFL-Care for Family
• PFL-Bonding
• PFL-Military
• PFL-Covid-19 Self/Employee
• PFL-Covid-19 Quarantine for Child
• EFT Authorization for PFL
• NYS DBL/PFL Telephonic Claims Submission Info
• Employer section for PFL requests
• PFL – 2021 NYS Mandate to Reporting Requirements
• DBL - Evidence of Insurability
• Equitable DBL Claim Form
• Stand-alone EFT Authorization for DBL/TDB

Administration Forms

Life

• Basic & Supplemental Life Portability
• Supplemental Life Portability
• Beneficiary Designation
• Beneficiary Change
• Conversion
• Portability and Conversion Flyer
• Life EOI

Dental

• COBRA
• ID Cards
• Privacy

Vision

• COBRA
• ID Cards
• Privacy
   

Worksite Products

Accident, Specified Disease and Hospital Portability Form