Db-450 Form - Notice And Proof Of Claim For Disability Benefits
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2NOTICE AND PROOF OF CLAIM FOR DISABILITY 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 GREEN CLAIM FORM DB-300.
PART B - HEALTH CARE PROVIDER'S STATEMENT (Please Print or Type)
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".
3. Sex ❑ Male
❑ Female
1. Claimant's Name
2. Age
4. Diagnosis/Analysis
Diagnosis Code
a. Claimant's Symptoms
b. Objective Findings
5. Claimant Hospitalized? ❑ Yes
❑ No
From
To
❑ Yes
❑ No
6. Operation Indicated?
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 date)
❑ Chiropractor
❑ Physician
❑ Psychologist
Licensed in the State of
License Number
I affirm that
❑ Dentist
❑ Podiatrist
❑ Nurse-Midwife
I am a
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 Code
PART C - EMPLOYER'S STATEMENT (Please Print or Type)
Policy Number:
Employee's Full Name:
S. S. Number:
Employee's Address:
Age:
Date
Full Time ❑
Part Time ❑
Employee's Occupation:
Employed
Is Employee a Union Member? ❑ Yes
❑ No Check Days Normally Worked
Mon. Tues. Wed. Thurs Fri. Sat. Sun.
If Part Time, Give Particulars:
Date Employee Last Worked:
EARNINGS 8 WEEKS PRIOR TO DISABILITY
(Including the week in which the disability began)
Date Employee's Wages Ceased:
No. Days
Date Employee Returned To Work:
Month
Day
Year
Amount
Worked
Wages Continued During Disability?
Is Reimbursement Requested?
Is Disability Due To Job?
If So, Has a Compensation Claim Been Filed?
Indicate Weekly Value of Board, Lodging, Tips $
Employer's Name
Employer's Identification No.
Percentage of Wkly. Disability Prem. paid by Employer
%
If blank we will assume the Employer pays 100% of the premium.
Total
Is this employee currently covered by Social Security? ❑ Yes
❑ No If No, state grounds for exemption.
Address
Date
Telephone No.
Signed by:
Title
DB-450 Reverse (11-98)
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
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