Form Db-450 - Notice And Proof Of Claim For Disability Benefits printable pdf download

NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS

CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY

WITHIN FOUR (4) WEEKS AFTER

1. USE THIS FORM IF YOU BECOME SICK OR DISABLED WHILE EMPLOYED OR IF YOU BECOME SICK OR DISABLED

TERMINATION OF EMPLOYMENT.

DB-300

BECOME SICK OR DISABLED AFTER HAVING BEEN UNEMPLOYED MORE

USE CLAIM FORM

IF YOU

THAN FOUR (4) WEEKS.

"CLAIMANT'S STATEMENT"

2. YOU MUST COMPLETE ALL ITEMS OF PART A - THE

BE ACCURATE. CHECK ALL DATES.

3. BE SURE TO DATE AND SIGN YOUR CLAIM (SEE ITEM 12). IF YOU CANNOT SIGN THIS CLAIM FORM, YOUR REPRESENTATIVE MAY SIGN IT IN YOUR

BEHALF IN THAT EVENT, THE NAME, ADDRESS AND REPRESENTATIVE'S RELATIONSHIP TO YOU SHOULD BE NOTED UNDER THE SIGNATURE.

DO NOT MAIL THIS CLAIM UNLESS YOUR HEALTH CARE PROVIDER COMPLETES AND SIGNS PART B - THE "HEALTH CARE PROVIDER'S

STATEMENT."

WITHIN THIRTY (30) DAYS AFTER YOU BECOME SICK OR DISABLED TO YOUR LAST EMPLOYER

5. YOUR COMPLETED CLAIM SHOULD BE MAILED

OR YOUR LAST EMPLOYER'S INSURANCE COMPANY.

6. MAKE A COPY OF THIS COMPLETED FORM FOR YOUR RECORDS BEFORE YOU SUBMIT IT.

PART A - CLAIMANT'S STATEMENT (Please Print or Type) ANSWER ALL QUESTIONS

Social Security Number

1. My name is .............................................................................................................

First

Middle

Last

2. Address.................................................................................................................................................................

Number

Street

City or Town

State

Zip Code

Apt. No.

3. Tel. No.......................................

4. Date of Birth...........................

5. Married (Check one)

Yes

6. My disability is (if injury, also state how, when and where it occurred) ............................................................................

.........................................................................................................................................................................................

Yes

7. I became disabled on .....................................................................

a. I worked on that day

Month

Day

Year

Yes

b. I have since worked for wages or profit.

No If "Yes", give dates ..............................................................

8. Give name of last employer. If more than one employer during the last eight (8) weeks, name all employers.

DATES OF EMPLOYMENT

EMPLOYER'S

AVERAGE WEEKLY WAGES

(Include Bonuses, Tips, Commissions,

FROM

THROUGH

BUSINESS ADDRESS

TELEPHONE NO.

BUSINESS NAME

Reasonable Value of Board, Rent, etc)

Mo.

Day

Yr.

Mo.

Day

Yr.

9. My job is or was ...................................................................................................

...................................................

Occupation

Name of Union and Local Number, if Member

10. For the period of disability covered by this claim

a. Are you receiving wages, salary or separation pay:..............................................................................

Yes

b. Are you receiving or claiming:

Yes

(1) Workers' compensation for work-connected disability..................................................................................

(2) Unemployment Insurance Benefits..............................................................................................................

Yes

(3) Damages for personal injury.......................................................................................................................

Yes

(4) Benefits under the Federal Social Security Act for long-term disability.........................................................

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 .......................

Date

11. I have received disability benefits for another period or periods of disability within the 52 weeks immediately before my

present disability began .............................................................................................................

Yes

If "Yes", fill in the following: I have been paid by ................................................... From ...................... To ....................

Date

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 PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR

BELEIF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT

OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.

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 will 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 Worker's 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, www.

wcb.state.ny.us. It can be found under the heading Common Forms Online. Mail the completed authorization form or letter to the address given below.

SI TIENE DUDAS RELACIONADAS CON LA RECLAMACION DE BENEFICIOS POR INCAPICIDAD,

F YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS,

CONTACT THE NEAREST OFFICE OF THE NYS WORKERS' COMPENSATION

COMUNIQUESE CON LA OFICINA MAS CERCANA DE LA JUNTA DE COMPENSACION OBRERA

BOARD, OR WRITE TO: WORKERS' COMPENSATION BOARD, DISABILITY

DE NUEVA YORK, O ESCRIBA A : WORKER'S COMPENSATION BOARD, DISABILITY BENEFITS

BENEFITS BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241-0005

BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241-0005

DB-450 (2-04)

HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERSE