Db-450 Form - Notice And Proof Of Claim For Disability Benefits Page 2
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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 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".
1. Claimant's Name ...................................................... 2. Date of Birth ....................... 3. Sex
Male
Female
4. Diagnosis/Analysis ...................................................................................................................................................
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
License Number
Chiropractor
Licensed in the State of
Physician
Psychologist
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 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.
Health Care Provider's Signature ............................................................................... Date ..................................
Health Care Provider's Name (Please Print) .............................................................. Tel.No. ..............................
Office Address ........................................................................................................................................................
Number
Street
City or Town
State
Zip
HIPAA NOTICE:
In order to adjudicate a workers' compensation claim, WCL 13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly
file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt
from HIPAA's restrictions on disclosure of health information.
PART C - EMPLOYERS STATEMENT
1. Employee's Name: ___________________________________________ POLICY NUMBER:
___________________
DBL-
______________
Date of Birth:
2. Employee's Occupation: _______________________________________ S.S. No.: _______________________ Age ____
# of hrs. worked on last day:
3. Date Employee Last Worked: ___________________________________
DATE EMPLOYED:
/
/20
FULL TIME
PART TIME
4. Date Employee's Wages Ceased: ________________________________
CHECK DAYS
Mon Tues. Wed. Thurs. Fri. Sat. Sun
5. Date Employee Returned To Work: _______________________________
NORMALLY WORKED
6. Wages Continued During Disability? ______________________________
EARNINGS 8 WEEKS PRIOR TO DISABILITY
If "Yes," through what date?
7. Is Reimbursement Requested? __________________________________
(Including the week in which the disability began)
8. Is Disability Due To Job? _______________________________________
NO. DAYS
YEAR
AMOUNT
MONTH
DAY
9. Name of Workers' Compensation Carrier: __________________________
If "Yes," is a compensation claim filed?
WORKED
10. Indicate Weekly Value of Board, Lodging, Tips $ ____________________
11. Is Employee A Member of a Union Which Provides
9.
N.Y. State Disability Benefits? ___________________________________
12. If Employee is no longer in your employ, check reason
10.
Labor Dispute
Lack of Work
Discharged
Quit
Explain ____________________________________________________
13. Is Claimant a
Proprietor
Owner
Partner
High School Student
14. Has Employee made a claim for Disability Benefits in the past 52 weeks?
11.
Yes
No. If Yes, Date _________________ 19 ____
15. Last Date Employee Received Unemployment Benefits: ______________
Yes
No
16. Does Employee Work For Anyone Other Than You
TOTAL
$0.00
(If blank we will assume 100%.)
__________________
17. Do Employees contribute toward their Disability premium? ____________
Percentage of Premium paid by employer:
12.
MAIL COMPLETED FORMS TO:
MAIL COMPLETED FORMS TO:
EMPLOYER'S NAME: _______________________________________________
Union Security Life Insurance Company of New York
THE FIRST REHABILITATION LIFE
ADDRESS: ________________________________________________________
INS. COMPANY OF AMERICA
ADMINISTRATIVE OFFICE
DATE: _________________ TELEPHONE: (
) __________________________
600 Northern Blvd.
P.O. Box 419244, Kansas City, MO 64141-6244
SIGNED BY: _________________________ TITLE: _______________________
Great Neck, NY 11021-5202
P.O. Box 972030, El Paso, TX 79997-2030
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
DB-450 (2-04)
Page 2 of 2
KC4732NY (12/2014)
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