Equitable's copy of the industry initial medical statement for group disability claims.
- Completed by
- Attending physician or other medical provider
- Issued by
- Equitable Life
- Format
- Fillable PDF
- Language
- English
Equitable Life Form 683: Proof of Death, Physician
Equitable Life uses this two-page proof of death for group life claims. The coroner or last physician in attendance certifies the cause of death in the international format, with the immediate cause, antecedent causes and other significant conditions, then adds when the deceased stopped working, attendance dates, any inquest or autopsy, three years of treatment history and smoking.
Who completes it
The coroner or the last physician in attendance completes the whole statement and signs it as family doctor or specialist. The claimant completes the Plan Member Death Claimant's Statement (Form 684), and the plan sponsor completes Form 210, or Form 209 for a dependant's death.
Submitting and payment
- How to submit it
- The completed form is faxed or mailed, without staples, to Equitable's Group Disability Claims Department, and the physician is asked to keep a copy.
- Who pays
- The form states that Equitable is not responsible for any fee for this information.
Good to know
- Enter only one cause on each of lines a, b and c, stating the underlying cause last, with the interval between onset and death for each.
- Line a is the disease, injury or complication that caused death, not the mode of dying such as heart failure or asthenia.
- The form asks whether the deceased was unable to work from the onset of disability and, if not, when they stopped working.
- Smoking history covers cigarettes, pipes, cigars, marijuana or other products and the approximate length of time; incomplete answers delay the assessment.
Get the official form
Download the current version from the source each time; forms change without notice.
Proof of Death – Physician’s Statement
Fill it with Vero
If your copy of the form is a fillable PDF, upload it 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.
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Frequently asked questions
Who can sign Equitable Life's Proof of Death Physician's Statement?
The form is to be completed by the coroner or the last physician in attendance. The signer indicates whether they are the family doctor or a specialist, with their specialty, address and telephone number, then signs and dates the statement before it is faxed or mailed to Equitable.
How should the cause of death be recorded on Equitable Form 683?
The form follows the medical certification recommended by the World Health Assembly in 1948 and asks you to conform to the International List of the Causes of Death. Enter one cause per line: the condition directly leading to death, then antecedent causes with the underlying cause last, plus other significant conditions.
Does Equitable pay for the proof of death physician's statement?
No. The form states that the company is not responsible for any fee for this information. It also warns that incomplete responses or missing information will cause delays in the assessment and handling of the file, so every question should be answered.