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 an 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
Colorado FAMLI Claim Form – Own Health Condition
Use this form if you need to file a claim for time off due to your own health condition.
Colorado FAMLI Claim Form – Bonding Leave
Use this claim form for claims related to bonding with a new child within 12 months of birth, adoption and foster care placement.
Colorado FAMLI 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.
Colorado FAMLI Claim Form – Pregnancy and/or Childbirth Complications
This form is to be used if you need to file a claim due to limitations related to pregnancy, childbirth or a related medical condition.
Colorado FAMLI Claim Form – Safe Leave
This form is to be used for claims under the Safe Leave provision, designed for survivors of sexual assault, domestic violence, harassment, or stalking.
Colorado FAMLI Claim Form – Military Exigency
This form is to be used if you need to file a claim due to a family members active duty service or notice of impending call to order to active duty.
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
Massachusetts Paid Medical Leave Claim Form
Use this claim form for Massachusetts Paid Family and Medical Leave Claims that are related to health conditions.
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.
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.
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.
For New Jersey Temporary Disability claims that are related to COVID-19
PLEASE READ TO SEE IF YOU QUALIFY FOR COVID-19 NEW JERSEY 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
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
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.
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.
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.
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.
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 issued by the state of New York, Department of Health, a local Board of Health or any other governmental entity, or have not signed the Affirmation of Quarantine form.
- 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:
- I was diagnosed with COVID-19, AND
- My Employer has less than 100 employees, AND
- I have an official Order of Quarantine for myself issued by the state of New York, Department of Health, a local Board of Health or any other governmental entity (shelter in place order issued by the New York governor is not an order of quarantine). For more information, visit: How do I obtain an Order of Quarantine.
For more information regarding the types of leave due to COVID-19, visit: NY State Paid Family Leave COVID 19.
Claim Forms
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.
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.
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.
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.
Paid Leave Oregon Claim Form – Bonding Certification
Use this form if you have a new child added to your family, either through birth, adoption or fostering.
Paid Leave Oregon Claim Form – Own Health Condition
Use this form if you need to file a claim for time off due to your own health condition.
Paid Leave Oregon Claim Form – Safe Leave
This form is to be used for claims under the Safe Leave provision, designed for survivors of sexual assault, domestic violence, harassment, or stalking.
Paid Leave Oregon 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.
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.
Arch STD/PFML Claim Form
Complete this form to file an Arch Insurance short term or paid family leave disability claim.
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.