Db-300 Form - Notice And Proof Of Claim For Disability Benefits By Unemployed Claimant

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STATE OF NEW YORK

WORKERS' COMPENSATION BOARD

DISABILITY BENEFITS BUREAU

100 BROADWAY-MENANDS

ALBANY, NY. 12241 - 0005

NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS BY UNEMPLOYED CLAIMANT

IMPORTANT: USE THIS FORM ONLY WHEN YOU BECOME SICK OR DISABLED AFTER FOUR (4) WEEKS OF UNEMPLOYMENT. OTHERWISE

USE CLAIM FORM DB-450. BEFORE COMPLETING THIS STATEMENT READ INSTRUCTIONS ON REVERSE SIDE.

PART A-CLAIMANT'S STATEMENT

(Please Print or Type)

a. My Social Security Number is:

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

(Please Print)

First

Middle

Last

2. a. Address..........................................................................................................................................................................................................

Number

Street

City or Town

State

Zip Code

Apt. No.

b. Tel. No..................................................... 3. Sex ........................ 4. Date of Birth........................................ 5. Married

Yes

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

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

7. The first day I was not "able to work" or became ineligible for Unemployment Insurance because of this disability was:

Month..................................Day.................................Year................ 8. Have you recovered from this disability?

Yes

If "Yes", what was the date you were able to work:

Month.......................................Day....................................Year.....................

9. My job is or was........................................................ 10. Union Member?

Yes

No If "Yes",...................................................

Occupation

Name of Union and Local Number

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

Average Weekly Wage

a. LAST EMPLOYER

PERIOD OF EMPLOYMENT

(Include Bonuses, Tips

Commissions, Reasonable

Value of Board, rent, etc.)

Firm or Trade Name

Address

Telephone No.

First Day

Last day worked

Mo. Day

Yr.

Mo. Day

Yr.

b. OTHER EMPLOYERS (during last eight (8) weeks)

PERIODS OF EMPLOYMENT

Firm or Trade Name

Address

Telephone No.

First Day

Last Day

12. Were you claiming or receiving unemployment prior to this disability?

Yes

a. If Yes, give U.I. Local Office No...........................Location.............................................Date you last reported..............................

b. If you did not claim or if you claimed but did not receive unemployment insurance benefits after LAST DAY WORKED, explain

reasons fully.....................................................................................................................................................................................

13. For the period of disability covered by this claim are you:

a. receiving wages or salary?

Yes

b. receiving,or claiming:

(1) Workers' Compensation for Work-connected Disability

Yes

(2) Damages for other Personal Injury

Yes

(3) Disability Benefits under the Federal Social Security Act

Yes

14. In the year (52 weeks) before your disability began, have you received disability benefits for other periods of disability?

Yes

No If yes, fill in the following: Paid by...................................................From....................................To...................................

I hereby claim Disability Benefits and certify that my disability began while I was unemployed; that I had been unemployed for more than four (4) weeks

before I became disabled; and that the foregoing statements, including any accompanying statements are, to the best of my knowledge, true and complete

SIGN

Claimant's Signature............................................................................................... Date claim signed..........................................................

If signed by other than claimant, print below: name, address, and relationship of representative.

HERE

Name and address..........................................................................................................................Relationship............................................

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 MUST COMPLETE PART B ON REVERSE SIDE

DB-300 (2-04)