Db-450 Form - Notice And Proof Of Claim For Disabilty Benefits
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1
2
3Administered by
Principal Life Insurance Company
State Disability
Des Moines, Iowa 50392-0002
Claim Form - NY
NOTICE AND PROOF OF CLAIM FOR DISABILTY BENEFITS
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 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.
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 THIRTY (30) DAYS AFTER YOU BECOME SICK OR DISABLED TO YOUR LAST EMPLOYER 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
no
6.
My disability is (if injury, also state how, when and where it occurred)
7.
I became disabled on
a. I worked on that day
yes
no
Month
Day
Year
b. 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 the last eight (8) weeks, name all employers.
EMPLOYER’S
DATES OF EMPLOYMENT
AVERAGE WEEKLY WAGES
(Include bonuses, tips,
BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
FROM
THROUGH
commissions, reasonable
Mo. Day Yr. Mo. Day Yr.
value of board, rent, etc.)
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
no
Are you receiving or claiming:
b.
(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
Date
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
no
If “yes”, fill in the following: I have been paid by
from
to
Date
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 BELIEF
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 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 authorization form or letter to the address given below.
IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS,
SI TIENE DUDAS RELACIONADAS CON LA RECLAMACIÓN DE BENEFICIOS
CONTACT THE NEAREST OFFICE OF THE NYS WORKERS' COMPENSATION
POR INCAPACIDAD, COMUNIQUESE CON LA OFICINA MAS CERCANA DE LA
BOARD, OR WRITE TO: WORKERS' COMPENSATION BOARD, DISABILITY
JUNTA DE COMPENSACIÓN OBRERA DE NUEVA YORK, O ESCRIBA A:
BENEFITS BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241-0005
WORKER'S COMPENSATION BOARD, DISABILITY BENEFITS BUREAU, 100
BROADWAY- MENANDS, ALBANY, NY 12241-0005
DB-450 (2-04)
GP12317-12
Page 1 of 3
05/2014
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