THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
Comments: Please include any other information you feel is relevant to this claim.
Employer name Telephone number Fax number
Address
(number, street and suite)
City Province Postal code
Date
(dd/mm/yyyy) Name and Title of Plan Administrator Signature of Plan Administrator
Plan administrator email
1. Employer/Plan Administrator Section (Form should be completed within 7 days of disability. Do not wait until the Plan Member returns to work.
A job description is required and can be provided in the following formats: Equitable Job description form (form 197) or Employer job description/
physical demands analysis. Incomplete responses or missing information will cause delays in the assessment and handling of this file.
Plan Member name (first, middle, last) Group Policy number Plan Member’s Certificate/Social Insurance Number
(Required for taxable benefits)
Date of hire (dd/mm/yyyy) Occupation Effective date of insurance If terminated/laid off, give date (dd/mm/yyyy)
(dd/mm/yyyy)
Date last worked Regular duties Date (dd/mm/yyyy)
Date returned to work Regular duties Date (dd/mm/yyyy)
For TPA and self-administered groups
please indicate the amount of Short Term Disability coverage: $
Regular Gross Earnings per week
(prior to disability) $
Deductions - section must be completed if your plan is Non-taxable (i.e. employee pays 100% of premiums)
Does Plan Member receive any pay or benefits while disabled?
Yes
No If “yes”, give details/comments in Comments section below
Income Tax $ C.P.P. $ E.I. $
Pension Plan $ Net Earnings $
Employees last paid date
(dd/mm/yyyy):
421B(2020/04/03)
SHORT TERM DISABILITY EMPLOYER COVID–19 CLAIM FORM
Head Office
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
TF 1.800.265.4556 T 519.886.5210
www.equitable.ca
PLEASE NOTE: Equitable Life cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail
may be vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is
intercepted and misused. If you would prefer to submit your information by another means, please contact us at 1.800.265.4556.
