Db-450 Form - Notice And Proof Of Claim For Disabilty Benefits Page 3
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3NOTICE AND PROOF OF CLAIM FOR DISABILTY BENEFITS
IMPORTANT: USE THIS FORM ONLY WHEN THE CLAIMANT BECOMES SICK OR DISABLED WHILE EMPLOYED OR BECOMES SICK OR
DISABLED WITHIN FOUR (4) WEEKS AFTER TERMINATION OF EMPLOYMENT. OTHERWISE USE CLAIM FORM DB-300.
Part B. – Health Care Provider’s Statement (Please print or type)
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic
information of employees or their family members. In order to comply with this law, we are asking that you not provide any genetic information when responding to this
request for medical information.
THE HEALTH CARE PROVIDER'S STATEMENT MUST BE FILLED IN COMPLETELY AND THE FORM MAILED TO THE INSURANCE CARRIER OR SELF-
INSURED EMPLOYER, OR RETURNED TO THE CLAIMANT WITHIN SEVEN DAYS OF THE RECEIPT OF THE FORM. For item 7d, give approximate date.
Make some estimate. If disability is caused by or arising in connection with pregnancy, enter estimated delivery date under "Remarks".
1.
Claimant’s name
2.
Date of birth
3.
Sex
male
female
4.
Diagnosis/analysis
Diagnosis code
a. Claimant’s symptoms
b. Objective findings
5.
Claimant hospitalized?
yes
no
from
to
6.
Operation indicated
yes
no
a. type
b. date
7.
Enter dates for the following:
month
day
year
a. Date of your first treatment for this disability
b. Date of your most recent treatment for this disability
c. Date claimant was unable to work because of this disability
d. Date claimant will be able to perform usual work
(Even if considerable question exists, estimate date. Avoid use of terms such as unknown or undetermined.)
8.
In your opinion, is this disability the result of injury arising out of and in the course of employment or occupational disease?
yes
no
If yes, has form C-4 been filed with the Workers' Compensation Board?
yes
no
Remarks (attach additional sheet, if necessary)
(If disability is pregnancy related, please enter estimated delivery)
I affirm that
chiropractor
physician
psychologist
Licensed in the state of
License number
I am a
dentist
podiatrist
nurse-midwife
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.
Health care provider’s signature
Date
Health care provider’s name (please print)
Tel. No.
Office address
Number
Street
City or Town
State
ZiP
Part C. – Employer Statement
Must be completed in full, by employer only immediately following claimant’s last day worked. For inquires, call 1-800-245-1522.
Employee’s name
Social security number
Age
Policy #
Employee’s occupation
Date of hire
If part-time, give particulars
full time
Coordinator/Distance Education Dep.
part time
owner
employee
Check one:
Check days normally worked
Actual last day worked Actual date paid through
proprietor
partner
Mon
Tu
Wed
Th
Fri
Sat
Sun
Wages continued during disability?
yes
no
GROSS EARINGS 8 WEEKS PRIOR TO DISABILITY
If yes, were wages Sick Pay?
yes
no from:
to:
(include tips, commissions, lodging and allowances)
Were wages Vacation Pay?
yes
no from:
to:
WEEK ENDING
NO. DAYS
GROSS
If employee received Sick Pay,
MO.
DAY
YEAR WORKED
AMOUNT
are you requesting reimbursement?
yes
no
1.
Has employee returned to work?
yes
no Date returned
2.
Did disability occur on the job?
yes
no
3.
If yes, was a Workers Comp. Claim filed?
yes
no
4.
Workers Comp. Carrier Name / Address / Phone #
5.
6.
% of employer contribution to premium for FICA Deductions =
%
7.
(If left blank, 100% will be deducted.)
8.
TOTAL $
Is employee a member of a union?
Does union provide disability benefits?
yes
no
yes
no If “yes”, provide name, address & phone # of union below.
Union’s name / address
Phone number
Employer’s name / address
Phone number
Signed by
Date
Title
GP12317-12
Page 3 of 3
05/2014
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