Disability Claims Management

Follow the instructions on this page to report a disability claim.

How to Report a Claim

To report a claim for disability insurance, follow the instructions presented based on the state of your employer.


All claim forms can be mailed, faxed or emailed (preferred) to:

Arch Insurance Company
PO Box #26316
Collegeville, PA 19426

Phone: 877-369-0979
Fax: 610-977-3216
Email: archdbl@acitpa.com

Claims administered by ACI on behalf of Arch Insurance. Policies underwitten by Arch Insurance Company.


Colorado

To report an Colorado Family and Medical Leave Insurance (CO FAMLI) claim, download and complete the appropriate claim form. Each form needs to be completed by the employee (claimant), employer, and for disability claims, the physician that is declaring the disability.

Claim Forms

pdf

Colorado FAMLI Claim Form – Own Health Condition

Use this form if you need to file a claim for time off due to your own health condition.

Available for download in multiple languages:
pdf

Colorado FAMLI Claim Form – Bonding Leave

Use this claim form for claims related to bonding with a new child within 12 months of birth, adoption and foster care placement.

Available for download in multiple languages:
pdf

Colorado FAMLI Claim Form – Serious Health Condition of a Family Member

Use this form if you need time off to care for a family member coping with their own serious health condition.

Available for download in multiple languages:
pdf

Colorado FAMLI Claim Form – Pregnancy and/or Childbirth Complications

This form is to be used if you need to file a claim due to limitations related to pregnancy, childbirth or a related medical condition.

Available for download in multiple languages:
pdf

Colorado FAMLI Claim Form – Safe Leave

This form is to be used for claims under the Safe Leave provision, designed for survivors of sexual assault, domestic violence, harassment, or stalking.

Available for download in multiple languages:
pdf

Colorado FAMLI Claim Form – Military Exigency

This form is to be used if you need to file a claim due to a family members active duty service or notice of impending call to order to active duty.

Available for download in multiple languages:

Connecticut

To report an Connecticut Paid Family and Medical Leave Insurance (CT PFML) claim, download and complete the appropriate claim form. Each form needs to be completed by the employee (claimant), employer, and for disability claims, the physician that is declaring the disability.

Claim Forms

pdf

Connecticut Family and Medical Leave Claim Form new tab icon

Use this claim form for Connecticut Paid Family and Medical Leave Claims that are related to health conditions.

pdf

Connecticut Family Leave Claim Form new tab icon

Complete this claim form for Connecticut Paid Family and Medical Leave requests related to child-bonding, military service or family violence.

Massachusetts

To report a Massachusetts Paid Family and Medical Leave (MA PFML) Claim, download and complete the appropriate Massachusetts claim form. This form is to be completed by the employee (claimant), employer and the physician that is declaring the disability.

If you are interested in submitting MA PFML claims online, please reach out to your HR Administrator.

Claim Forms

pdf

Massachusetts Paid Medical Leave Claim Form

Use this claim form for Massachusetts Paid Family and Medical Leave Claims that are related to health conditions.

Available for download in multiple languages:
pdf

Massachusetts Paid Family Leave Claim Form

Complete this claim form for Massachusetts Paid Family and Medical Leave requests related to child-bonding or military service.

Available for download in multiple languages:
pdf

Massachusetts Maternity Leave to Child Bonding Claim Form

Use this claim form to convert Massachusetts Paid Medical Leave into Paid Family Leave after the birth of a child.

Available for download in multiple languages:

New Jersey

To report a New Jersey Disability claim, download and complete the NJ-TDB claim form. This form is completed by the employee (claimant), employer and the physician that is declaring the disability.

pdf

New Jersey Temporary Disability Benefits Claim Form

Use this claim form for New Jersey Temporary Disability Benefits leave that are related to health conditions.

Available for download in multiple languages:

New York

To report a New York Disability claim, download and complete the DB-450 claim form. Usage of out-of-date claim forms may be rejected.

To report a New York Paid Family Leave claim, download and complete the appropriate forms that corresponds to your request (Bonding, Caring for a Family Member, Military).

Each form needs to be completed by the employee (claimant), employer and for disability claims, the physician that is declaring the disability.

New York has a new Paid Sick Leave law. Find out how much more paid sick leave you can receive as a New York employee.

Claim Forms

pdf

New York DB-450 Disability Claim Form

Use this claim form for New York Disability Claims that are related to maternity leave and health conditions.

Available for download in multiple languages:
pdf

New York Paid Family Bonding Leave Claim Form

Use this claim form for New York Paid Family Leave Claims that are related to bonding with your child within 12 months of birth, adoption and foster placement.

Available for download in multiple languages:
pdf

New York Paid Family Caring for a Family Member Claim Form

Use this claim form for New York Paid Family Leave Claims that are related to caring for a family member with a serious health condition.

Available for download in multiple languages:
pdf

New York Paid Family Military Leave Claim Form

Use this claim form for New York Paid Family Leave Claims that are related to assisting loved ones when a family member is deployed abroad.

Available for download in multiple languages:

Oregon

To report an Oregon Paid Family and Medical Leave (OR PFML) claim, download and complete the appropriate claim form. Each form needs to be completed by the employee (claimant), employer, and for disability claims, the physician that is declaring the disability.

pdf

Paid Leave Oregon Claim Form – Bonding Certification

Use this form if you have a new child added to your family, either through birth, adoption or fostering.

Available for download in multiple languages:
pdf

Paid Leave Oregon Claim Form – Own Health Condition

Use this form if you need to file a claim for time off due to your own health condition.

Available for download in multiple languages:
pdf

Paid Leave Oregon Claim Form – Safe Leave

This form is to be used for claims under the Safe Leave provision, designed for survivors of sexual assault, domestic violence, harassment, or stalking.

Available for download in multiple languages:
pdf

Paid Leave Oregon Claim Form – Serious Health Condition of a Family Member

Use this form if you need time off to care for a family member coping with their own serious health condition.

Available for download in multiple languages:

LeaveAssure — Non-Statutory Short Term Disability and Paid Family Leave

To report a Short Term Disability Claim, download and complete the STD/PFL claim form. This form is completed by the employee (claimant), employer and the physician that is declaring the disability.

pdf

Arch STD/PFML Claim Form

Complete this form to file an Arch Insurance short term or paid family leave disability claim.

Available for download in multiple languages:

Information

Insurance coverage is underwritten by a member company of Arch Insurance Group Inc. This is only a brief description of the insurance coverage(s) available under the policy. The policy contains reductions, limitations, exclusions and termination provisions. Full details of the coverage are contained in the policy. If there are any conflicts between this document and the policy, the policy shall govern. Not all coverages are available in all jurisdictions.

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