Disability Claims Management

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

To report a claim for disability insurance, follow the instructions below 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: [email protected]com

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

Massachusetts

To report a Massachusetts Paid Family and Medical Leave 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

Massachusetts Paid Medical Leave Claim Form

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

Download

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.

Download

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.

Download

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 Jersey Temporary Disability Benefits Claim Form

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

Download

For New Jersey Temporary Disability claims that are related to COVID-19

PLEASE READ TO SEE IF YOU QUALIFY FOR COVID-19 NJ BENEFITS:

I DO NOT qualify for a New Jersey COVID-19 temporary disability claim if:

  • My company closed or I have less hours available due to business slow down. You may be eligible for Unemployment Insurance.
  • You contracted the virus because you waited on or worked with someone who had the virus, or contracted the virus for any other work related reason. You could be eligible for Workers Compensation.

I MAY qualify for a New Jersey COVID-19 temporary disability claim if:

  • I was diagnosed with COVID-19 or a healthcare provider has certified I am a greater risk due to pre-existing conditions after March 25, 2020, AND
  • I have an official Order of Quarantine for myself issued by a health care provider, the state of NJ, Dept. of Health, a local Board of Health or any other governmental entity.

Additional Resource Guides to COVID-19 Benefits

Worker Benefits, Protections and the Coronavirus (COVID-19): What NJ Workers Should Know

COVID-19 Scenarios & Benefits Available

New York

To report a New York Disability claim, download and complete the DB-450 claim form.

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 NY employee.

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.

Download

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.

Download

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.

Download

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.

Download

For New York Disability claims that are related to COVID-19

PLEASE READ TO SEE IF YOU QUALIFY FOR COVID-19 NY BENEFITS:

I DO NOT qualify for a New York COVID-19 disability claim if:

  • My employer has 100 or more employees
  • I do not have an official Order of Quarantine for myself, dependent child or a family member issued by the state of NY, Dept. of Health, a local Board of Health or any other governmental entity.
  • My business temporarily closed, I was laid off/furloughed, school closed for preventive social distancing.

If any above apply, you may be eligible for Unemployment Insurance.

I MAY qualify for a New York COVID-19 disability claim if:

  • Myself or a family member was diagnosed with COVID-19, AND
  • My Employer has less than 100 employees, AND
  • I have an official Order of Quarantine for myself, dependent child or a family member that I am taking care of, issued by the state of NY, Dept. of Health, a local Board of Health or any other governmental entity (shelter in place order issued by the NY governor is not an order of quarantine). For more information, visit: How do I obtain an Order of Quarantine.

Submit a NY COVID19 Claim online

NY COVID-19 Online Claim Instructions

Additional Resources:

NY Claim Form for Paid Family Leave – COVID-19 Quarantine for a Minor Dependent Child (CCOVID19)

Complete this form to submit a claim to care for a dependent minor child during their COVID-19 quarantine under the Paid Family Leave benefit for New York.

Download

NY Claim Form for Paid Family Leave – COVID-19 Quarantine for Self (SCOVID19)

Complete this form to submit a claim due to your own quarantine or isolation due to COVID-19 under the Paid Family Leave benefit for New York.

Download

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.

Download

New York COVID-19 Coverage

Under legislation signed by Governor Cuomo, New York workers are guaranteed job protection and financial compensation while they are on a mandatory or precautionary quarantine order due to COVID-19.

Download

Short Term Disability and Paid Family Leave – LeaveAssure – All Other States

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.

Arch STD/PFML Claim Form

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

Download

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.