Form Db-450 - Notice And Proof Of Claim For Disability Benefits
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1
2NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
State Disability Claims
P.O. Box 14332
Lexington, KY 40512
Telephone#1-800-268-2525
Fax# 610-807-2953
Secure E-mail: , click Secure Channel, select
CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY
1. Use this form if you become sick or disabled while employed or if you become sick or disabled within four (4) weeks after termination of employment. Use claim form
DB-300 if you become sick or disabled after having been unemployed more than four (4) weeks.
2. You must complete all items of part A – The “CLAIMANT’S STATEMENT”. Be accurate. Check all dates.
3. Be sure to date and sign your claim (see item 12). If you can not sign this form, your representative may sign it on your behalf. In that event, the name, address and
representative’s relationship to you should be noted under the signature.
4. Do Not Mail this Claim unless your Health Care Provider Completes and signs Part B – The “HEALTH CARE PROVIDER’S STATEMENT”.
5. Your completed claim should be mailed WITHIN 30 DAYS after you become sick or disabled to your last employer or your last employer’s insurance company.
PART A – CLAIMANT’S STATEMENT (Please Print or Type) ANSWER ALL QUESTIONS
1. Name:
Policy #:
Social Security #:
(
First, Middle, Last)
2. Address:
Apt. #
City
State
Zip Code
3. Telephone #:
4. Date of Birth:
5. Married (Check one):
Yes
No
5a.
Male
Female
6. My disability is (if injury, also state how, when and where it occurred)
7. I became disabled on
7a. I worked on that day
Yes
No
____ /____ /____
Mo.
Day
Year
7b. I have since worked for wages or profit
Yes
No
If "Yes" give dates:
8. Give name of last employer. If more than one employer during last eight (8) weeks, name ALL employers.
Dates of Employment
Average Weekly Wages
(Include Bonuses, Tips,
From
Through
EMPLOYERS
Commissions Reasonable
Business Name
Business Address
Telephone No.
Mo. Day Yr. Mo. Day Yr.
Value of Board, Rent, Etc.)
9. My job is or was (Occupation
Name of Union and Local No., if Member
)
10. For the period of disability covered by this claim:
a. Are you receiving wages, salary or separation pay
YES
NO
b. Are you receiving or claiming:
(1) Workers Compensation for work-connected disability
YES
NO
(2) Unemployment Insurance Benefits
YES
NO
(3) Damages for personal injury
YES
NO
(4) Benefits under the Federal Social Security Act for long-term disability
YES
NO
IF “YES” IS CHECKED IN ANY OF THE ITEMS IN 10a OR 10b, COMPLETE THE FOLLOWING:
I have
Received
Claimed from __________________ For the Period __________________ To ____________________ .
11. I have received disability benefits for another period or periods of disability within the 52 weeks immediately before my present disability
began.
YES
NO If Yes, fill in the following: I have been paid by
From
To
______________
_____________
_____________
12. I have read the instructions above. I hereby claim Disability Benefits and certify that for the period covered by this claim I was disabled: and
that the foregoing statements, including any accompanying statements, are to the best of my knowledge true and complete.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY FILES A STATEMENT OF CLAIM
CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION
CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
Claim signed on: Date
Claimant’s Signature
If signed by other than claimant, PRINT below: name, address, and relationship of representative.
Disclosure of Information: The Board does not disclose any information about your case to any unauthorized party without your consent. If you
choose to have such information disclosed to an unauthorized party, you must file with the Board an original signed form OC-110A, Claimant’s
Authorization to Disclose Workers; Compensation Records, or an original signed, notarized authorization letter. You may telephone your local
WCB office to have Form OC-110A sent to you, or you may download it from our web page,
It can be found under the heading
Common Forms Online. Mail the completed form or letter to the address given below.
IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS, CONTACT THE NEAREST OFFICE
SI TIENE DUDASRELACIONADAS CON LA RECLAMACION DE BENEFICIOS POR INCAPACIDAD,
OF THE NEW YORK STATE WORKERS COMPENSATION BOARD, OR WRITE TO: WORKERS’ COMPENSATION
COMUNIQUESE CON LA OFICINA MAS CERCANA DE LA JUNTA DE COMPENSACION OBRERA DE NUEVA
BOARD, DISABILITY BENEFITS BUREAU,
YORK, O ESCRIBA A: WORKERS COMPENSATION BOARD, DISABILITY BENEFITS BUREAU,
100 BROADWAY-MENANDS, ALBANY, N.Y. 12241-0005.
100 BROADWAY-MENANDS, ALBANY, N.Y. 12241-0005.
DB-450 (Rev. 5/14)
HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERSE
After Parts A, B, & C are completed, Mail to: Guardian – State Disability Claims – P.O. Box 14332, Lexington, KY 40512 or
Fax: 610-807-2953 or email: Secure E-mail: , click Secure Channel, select
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