What the 1741 is for
The 1741 supports a request for a compassionate advance, one of the KIND benefits Equitable includes with some of its whole life, universal life, and term life policies. The advance pays part of the death benefit early when the insured has a disease or injury expected to cause death within 24 months of diagnosis. Equitable sets the amount at 50% of the base coverage, up to $100,000, less policy loans and withdrawals.
The form is sometimes confused with the 2115, Equitable’s disability benefits statement. The 2115 asks about work capacity and recovery. The 1741 has no work questions and turns on a single prognosis question about life expectancy. It’s also separate from a critical illness claim, which pays on the diagnosis of a listed condition.
Who completes it
The patient completes Part 1, the patient authorization, with their policy number, name, date of birth, address, phone, and email, and signs the release of medical information to Equitable and the policy owner. The attending physician completes Part 2 and signs it with their name, specialty, phone, fax, email, and address.
These requests come at a hard time, and the family often handles the paperwork. Part 1 tends to arrive signed in a hospital room or at home, then gets dropped at the clinic for you to finish Part 2 by hand. In Medulla, you send Part 1 to the patient or their family over a secure link. They fill it in on the form from a phone, and their answers land on the PDF you complete Part 2 on, so nobody has to make an extra trip to the clinic.
How to fill in Part 2
History
Give the date symptoms first appeared or the accident happened. Say whether the patient has had the same or a similar condition before, with details if so, and list the names and contact information of the other treating physicians and providers. Equitable uses that list to request records, so include the oncologist, palliative team, or specialist who made the diagnosis.
Diagnosis
Enter the primary diagnosis with any complications, then the subjective symptoms and the objective signs. The form asks you to attach current test results and the clinical findings that support the diagnosis. Pathology, imaging, and the specialist’s consultation note are what Equitable reads.
Treatment and progress
Give the dates of the first and last visits, how often you see the patient, and the nature of treatment, including surgery, therapies, and medications. Say whether the patient is following the recommended program. Then mark whether the patient has recovered, improved, not improved, or retrogressed.
Prognosis
Answer yes or no to whether the condition is expected to result in a life expectancy of less than 24 months. This is the question the advance depends on. If the answer rests on a specialist’s opinion, say so in the remarks and attach the report.
Remarks
Use the remarks for the context the boxes don’t hold: staging, disease progression, response to treatment, or a palliative care referral.
Common reasons it’s delayed
- Part 1 not signed by the patient.
- The prognosis question left blank or answered with “uncertain”.
- No test results or specialist reports attached to support the diagnosis.
- Other treating physicians not listed, so Equitable can’t get the records.
- Missing physician signature, contact details, or date.
Submitting and who pays
The completed form goes back to Equitable with the compassionate advance request. The form prints Equitable’s Waterloo head office address and toll-free number. It doesn’t set a fee for completing the statement, so agree any fee with the patient or family as an uninsured service.