Db-470 - Claim For Reimbursement Of Benefits Paid Under The New York Disability Benefits Law

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STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
Preliminary Claim
DISABILITY BENEFITS LAW
Final Claim
CLAIM FOR REIMBURSEMENT OF BENEFITS PAID
UNDER THE NEW YORK DISABILITY BENEFITS LAW
1. CLAIMANT'S SOC. SEC. NO.
2. D.B. CARRIER'S FILE NO.
3. DATE OF ACCIDENT OR INJURY
4. W.C.B. CASE NO.
5. W.C., V.F.B. OR V.A.W.B. CARRIER CASE NO. 6. CARRIER CODE
7.DATE OF PRELIMINARY CLAIM
8. DATE OF FINAL CLAIM
FOR REIMBURSEMENT
FOR REIMBURSEMENT
9. AMOUNT OF REIMBURSEMENT CLAIMED
Claimant's Name__________________________________________________________
$
*
Employer's Name__________________________________________________________
Carrier's Name __________________________________________________________________________________________
W.C., V.F.B. or V.A.W.B. Carrier
*In volunteer firefighters' and volunteer ambulance workers' benefit cases, the liable political subdivision is deemed to be the "EMPLOYER."
Notice is hereby given and claim made under the provisions of Section 206, subdivision 2, of the New York Disability Benefits Law for
reimbursement out of the proceeds of the workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit award, if
any, to the claimant for the period for which disability benefits were paid under the provisions of the New York Disability Benefits Law in
connection with the above case during a time when the injured claimant's right to workers' compensation, volunteer firefighters' or volunteer
ambulance workers' benefits had not been determined.
Benefits under the Disability Benefits Law are paid to:
Name____________________________________________________________________________________________________
Address___________________________________________________________________________________________________
a total
From_______________to________________at a rate of $_______________per_______________, payment of________________
Date Form
Date medical
Date first
C-7 received____________________
evidence received____________________ payment mailed_________________________
NOTICE TO CLAIMANT
Disability benefits are being paid to you pending a decision on
your claim for workers' compensation, volunteer firefighters' or
volunteer ambulance workers' benefits.
Since you may not
NAME OF DISABILITY BENEFITS CARRIER, EMPLOYER OR TRUSTEE
collect both disability benefits and any of these other benefits for
the same disability, any subsequent award for workers'
compensation, volunteer firefighters' or volunteer ambulance
ADDRESS
workers' benefits will be reduced by the amount of disability
benefits paid, for reimbursement to the disability benefits carrier.
By
NOTICE TO CARRIER
Complete each item on this form and file with (1) the Workers'
Title
Compensation Board (see mailing addresses below) (2) the
workers' compensation, volunteer firefighters' or volunteer
ambulance workers' benefit insurance carrier, (3) the claimant
Telephone Number
and his or her representative, if any, before award of
compensation, volunteer firefighters' or volunteer ambulance
workers' benefit is made.
DOWNSTATE CENTRALIZED MAILING
100 Broadway
State Office Building
Statler Towers
(for New York City, Hempstead, Hauppauge & Peekskill Districts)
Menands
130 Main Street W.
935 James St.
44 Hawley Street
107 Delaware Ave.
PO Box 5205 Binghamton,
13902-5205
NY
ALBANY 12241
ROCHESTER 14614
SYRACUSE 13203
BINGHAMTON 13901
BUFFALO 14202
(866) 750-5157
(866) 211-0644
NYC (800)877-1373/Hemp. (866)805-3630/Haup.(866)681-5354/Peek. (866)746-0552
(866) 802-3730
(866) 802-3604
(866) 211-0645
DB-470 (12-05)
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.

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