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The document provides claim submission instructions and identifies four required sections: employer statement, employee statement, authorization to obtain and disclose information, and attending physician’s statement. It also includes the employer section fields for employee identity, employment details, coverage and leave history, tax withholding/reporting inputs, and core claim information needed to process the disability benefit request.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/employee-benefits-disability-std-claim-form/303125/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/employee-benefits-disability-std-claim-form/303125.png","ImageObject",442,249,{"name":88,"@type":89},"Rowan","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-04","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who must complete each section of the STD claim form?","Question",{"text":108,"@type":109},"Section I is completed by the employer’s authorized representative, Section II by the employee applying for STD benefits, Section III must be signed by the employee, and Section IV is completed by the attending physician or medical provider treating the employee.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How should the completed application be submitted to Equitable?",{"text":113,"@type":109},"Send the completed application to Equitable, Attn: EB Claims, using the provided email, fax number, or mailing address included in the instructions.",{"name":115,"@type":106,"acceptedAnswer":116},"What information is required in the employer’s statement related to taxes?",{"text":117,"@type":109},"The employer must provide the taxable percent of the STD benefit, employer contribution details (including whether a Gross-Up applies), and whether employee contributions are pre-tax or post-tax, plus any required context for tax treatment.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},303125,1790127168,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":35,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":140},1099514067415,"https://ap-avatar.wpscdn.com/avatar/100002539d78ffe74a7?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779092875211072502","Equitable Financial Life Insurance Company / Equitable Financial Life Insurance Company of America  \nFor Assistance Call (866) 274-9887  \nSHORT TERM DISABILITY INCOME (STD)  \nCLAIM FORM INSTRUCTIONS  \nSection I Employer's Statement-to be completed by the employer's authorized representative.  \nSection II Employee's Statement-to be completed by the employee who is applying for Short Term Disability Benefits  \nSection III AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION-to be signed by the employee.  \nSection IV Attending Physician's Statement - to be completed by the medical provider who is treating the employee.  \nPLEASE SEE THAT ALL SECTIONS ARE FULLY COMPLETED AND SIGNED.  \nSEND COMPLETED APPLICATION TO EQUITABLE  \nPlease email, fax or mail the completed application to: Equitable  \nAttn: EB Claims  \n8501 IBM Drive, Suite 150-C  \nCharlotte, NC 28262  \nFax Number:(315) 477-2499  \n[Email: ebclaims@equitable.com](Email: ebclaims@equitable.com)  \nQuestions? Once the claim has been filed you can call Equitable Claims at (866) 274-9887  \nEquitable is the brand name of the retirement and protection subsidiaries of Equitable Holdings, Inc., including Equitable Financial Life Insurance Company (NY, NY); Equitable Financial Life Insurance Company of America, an AZ stock company with an administrative office located in Charlotte, NC; and Equitable Distributors, LLC. The obligations of Equitable Financial Life Insurance Company and Equitable Financial Life Insurance Company of America are backed solely by their claims-paying abilities.  \nPage 1 of 1  \nEBSTDINSTR (07/30/2026)  \nSend completed form to:  \nEquitable, EB Claims  \n8501 IBM Drive, Suite 150-C Charlotte, NC 28262 Fax Number: (315) 477-2499  \n[ebclaims@equitable.com](ebclaims@equitable.com)  \nSHORT TERM DISABILITY INCOME (STD) CLAIM FORM  \nEquitable Financial Life Insurance Company / Equitable Financial Life Insurance Company of America For Assistance Call (866) 274-9887  \nSection I -Employer's Section-To Be Completed by the Employer  \n\n| Employee Name (first) |  | (middle name) |  | (last name) |\n| --- | --- | --- | --- | --- |\n| Social Security/Tax Identification \\# | Date of Birth |  | Telephone | Number |\n| Employee’s Address\u003Cbr>Street |  | City State |  | Zip |\n\nA. Information About the Employer  \n\n| Company’s Name |  |  |\n| --- | --- | --- |\n| Company’s Address\u003Cbr>Street City State Zip |  |  |\n| Name and Address of Division Where Employee Works (if different from above) |  |  |\n| Division Name | Division Address\u003Cbr>Street City State Zip |  |\n| Group Policy Number | Class | Location |\n\nB. Information About the Employee  \n\n| Date employee was hired | Date employee became insured under the plan | Is employee a union member? ☐ No ☐ Yes\u003Cbr>If “Yes,” name of union   Union local number   |\n| --- | --- | --- |\n| What was the employee's regularly scheduled work week?\u003Cbr>  Hours per Week Scheduled workdays ☐ Monday – Friday ☐ Other:   |  |  |\n| Is employee covered under a Long-Term Disability plan insured by Equitable? ☐ No ☐ Yes If “Yes,” Effective date of LTD coverage: |  |  |\n| Was the employee’s Short-Term Disability insurance issued on the basis of a Personal Heath Statement? ☐ Yes ☐ No If “Yes,” attach copy |  |  |\n| Was the employee insured under your prior Short-Term Disability policy? ☐ Yes ☐ No\u003Cbr>If yes, please provide the inclusive date of coverage From  Through   |  |  |\n| Was the employee on Qualified Family Leave when disability began? ☐ Yes ☐ No Did STD &/or LTD insurance continue while on Family Leave? ☐ Yes ☐ No Date Qualified Family Leave started:  \u003Cbr>Is this an Incremental Voluntary STD plan? ☐ Yes ☐ No\u003Cbr>If “Yes”, please provide the Employee Elected Amount: $ 00\u003Cbr>Section-I continued in next page. |  |  |\n\nEquitable is the brand name of the retirement and protection subsidiaries of Equitable Holdings, Inc., including Equitable Financial Life Insurance Company (NY, NY); Equitable Financial Life Insurance Company of America, an AZ stock company with an administr","cbCairjVKAwgqsGY","https://ap.wps.com/l/cbCairjVKAwgqsGY","pdf",339953,"English","# Claim Form Instructions\n## Required Sections\n# Employer's Section\n## Employee and Employment Information\n## Withholding and Reporting Taxes\n## Claim Details and Salary Information","[{\"question\":\"Who must complete each section of the STD claim form?\",\"answer\":\"Section I is completed by the employer’s authorized representative, Section II by the employee applying for STD benefits, Section III must be signed by the employee, and Section IV is completed by the attending physician or medical provider treating the employee.\"},{\"question\":\"How should the completed application be submitted to Equitable?\",\"answer\":\"Send the completed application to Equitable, Attn: EB Claims, using the provided email, fax number, or mailing address included in the instructions.\"},{\"question\":\"What information is required in the employer’s statement related to taxes?\",\"answer\":\"The employer must provide the taxable percent of the STD benefit, employer contribution details (including whether a Gross-Up applies), and whether employee contributions are pre-tax or post-tax, plus any required context for tax treatment.\"}]","Employee Benefits - Disability - STD Claim Form | PDF",1789800018,6]