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.
Choose the Appropriate Option
Colorado
To report a 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
Connecticut
To report a 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
Connecticut Family and Medical Leave Claim Form
Use this claim form for Connecticut Paid Family and Medical Leave Claims that are related to health conditions.
Connecticut Family Leave Claim Form
Complete this claim form for Connecticut Paid Family and Medical Leave requests related to child-bonding, military service or family violence.
Delaware
To report a Delaware Paid Family and Medical Leave (DE 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
Delaware Paid Leave Claim Form – Own Health Condition
Use this form if you need to file a claim for time off due to your own health condition.
Delaware Paid Leave Claim Form – Bonding Leave
Use this claim form for claims related to bonding with a new child, adoption and fostering of a child.
Delaware Paid Leave 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.
Delaware Paid Leave Claim Form – Military Exigency
This form is to be used if you need to file a claim due to issues that arise in connection with military deployment.
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
Minnesota
To report a Minnesota Paid Family and Medical Leave (MN 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
Minnesota Paid Leave Claim Form – Own Health Condition
Use this form if you need to file a claim for time off due to your own health condition.
Minnesota Paid Leave Claim Form – Bonding Leave
Use this form for claims related to bonding with a new child, adoption, or foster placement.
Minnesota Paid Leave 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.
Minnesota Paid Leave Claim Form – Military Exigency
Use this form to file a claim to support a family member called to active duty.
Minnesota Paid Leave Claim Form – Safety Leave
Use this form to respond to issues related to domestic violence, sexual assault, or staking for yourself or a family member.
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.
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
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.
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.
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.