Please choose the form associated with the state in which your employer is headquartered. This may or may not coincide with your state of residence, however, please only use the form corresponding to the state in which your employer is headquartered. (Note: If a printable version is needed, please contact our Employee Benefits team at EOIprocessing@equitable.com and include the group or member certification number.)
Completed form must be signed, dated and returned to Equitable within 31 days of becoming eligible for the coverage.
- California
- Florida
- New York
- North Dakota
- South Dakota
All other states