Physician's proof-of-death statement for a group life insurance claim.
- Completed by
- Coroner or last physician in attendance
- Issued by
- Equitable Life
- Format
- Language
- English
Equitable Form 2274: Disability Medical Statement
Equitable Life's Form 2274 is its copy of the industry Initial Disability Insurance Medical Statement (June 2025 version), used for group short- and long-term disability claims. Equitable also accepts the industry statement for life insurance premium waivers and for absences referred to its QuickAssess service. Once all required forms arrive, Equitable says it reviews a disability claim within five business days.
Who completes it
The plan member completes Section 1 and the Disability Claim, Plan Member form (2330), and the plan sponsor completes Form 2331. The doctor or nurse practitioner completes the medical statement.
Submitting and payment
- How to submit it
- Documents can be uploaded through the Document Submission Tool on EquitableHealth.ca, faxed, or mailed to Equitable's group disability claims team in Waterloo.
- Who pays
- Equitable's claims guide states that plan members are responsible for any costs of completing the forms.
Good to know
- Equitable asks for short-term disability claims within seven days of the first day off work, and long-term claims at least eight weeks before the elimination period ends.
- If the patient has had tests or seen specialists, Equitable asks the doctor to provide copies of the test results and specialist reports.
- During a leave, Equitable checks in regularly and asks for updated medical information, working with the employer and health care providers on a return-to-work plan.
- Appeals must be made in writing within 60 days of the decision letter, and the plan member pays for any additional medical details provided.
Get the official form
Download the current version from the source each time; forms change without notice.
Disability Insurance medical statement
Fill it with Vero
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Can a nurse practitioner complete Equitable's disability medical statement?
Yes. Equitable's disability claims guide asks plan members to have their doctor or nurse practitioner complete the Initial Disability Insurance Medical Statement, and names the physician or nurse practitioner for waiver of premium claims too. Section 2 of the form has an Other box for the applicable medical provider.
Who pays for Equitable Form 2274?
The plan member. Equitable's guide says plan members are responsible for any costs associated with completing the forms, and the statement itself says the patient is responsible for completion fees. The guide adds that members also pay for any additional medical details provided for an appeal.
How quickly does Equitable decide a disability claim?
Equitable says it reviews disability claim forms within five business days of receiving all required documents. It may call the plan member about their condition, job and daily activities, then contacts both the member and the employer with the decision and, if approved, the benefit details.