Form Db-451 - Notice Of Total Or Partial Rejection Of Claim For Disability Benefits
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1
2ENTER CARRIER NAME/ADDRESS HERE
TO THE CLAIMANT: THE
OFFICE IDENTIFIED AT THE
RIGHT ISSUED THIS NOTICE.
NOTICE OF TOTAL OR PARTIAL REJECTION OF CLAIM FOR DISABILITY BENEFITS
AVISO DE TOTAL O PARCIAL RECHAZO DE RECLAMACION DE BENEFICIOS POR INCAPACIDAD
THIS FORM MUST BE USED BY SELF-INSURED EMPLOYERS, UNIONS OR ASSOCIATIONS AND INSURANCE CARRIERS TO REJECT ALL OR
This notice is to be mailed to the claimant in triplicate within 45 days, to give the claimant
PART OF A CLAIM FOR DISABILITY BENEFITS.
opportunity of filing the notice with the Chair, Workers' Compensation Board for the purpose of review.
check each item on
IMPORTANT:
which claim is being rejected. If reason No. 5,7,9,or 10 is checked, enter explanation in space provided in No.11.
Claimant
Date of this Notice
Social Security No.
Date Claim Received
First Day of
Carrier Claim/File No.
(by employer or carrier,whichever is
Disability
earlier)
Claim Filed
DB-450
C-7 (Sec.206.2)
(Check one)
DB-300
WCB Case No._______________________
Employer
Address
Policy Holder or Union (If Different from Employer)
Address
Benefits paid on this claim
Amount
None
From____________________To______________________Per Week $______________
prior to the date of this notice
You are hereby notified that your claim for disability benefits is rejected for the reason(s) checked below:
5.
Your record of employment is not sufficient to establish your
1.
Payment of benefits is rejected after_____________________
the date you could return to work according to medical
eligibility for disability benefits. PLEASE SEE ITEM NO. 11.
6.
Your disability began more than 4 weeks after your
vidence on file. If you were still disabled after that date,
employment terminated. Your claim, together with copies of
submit additional medical evidence immediately.
this notice and our related records, is being forwarded to
2.
Your claim was filed more than 26 weeks after your
the Workers' Compensation Board, Special Fund for
disability began.
Disability Benefits, for consideration.
3.
Notice and proof of disability was not furnished within 30
7.
You have received either 26 weeks of benefits, the maximum
days (See Dates Above.) after disability began. (See item 4
payable during a period of 52 consecutive weeks or for any
on reverse.)
one disability; or you have received the maximum payable
(A)
No benefits payable.
(B)
Payments are being made beginning 2 weeks
under a Disability Benefits plan filed with the Workers'
Compensation Board. PLEASE SEE ITEM NO. 11.
prior to the date your claim was received.
8.
Your disability arose out of and in the course of your
Benefits are payable from_________________________
employment. We suggest you notify your employer and
4.
We are not your last employer's Disability Benefits
Insurance carrier.
obtain a claim for Workers' Compensation (Form C-3) from
the nearest Workers' Compensation Board Office.
(A)
Your claim has been forwarded to:
9.
You failed to furnish, as requested, information necessary to
_______________________________________________
process your claim. PLEASE SEE ITEM NO.11.
(B)
Your claim is returned herewith. We suggest you
10.
Other - PLEASE SEE ITEM NO.11
give it to your employer for submission to the proper
carrier or forward it to the Workers' Compensation Board,
Disability Benefits Bureau, 100 Broadway-Menands, Albany,
NY 12241-0005.
11. Explanation
____________________________________________ _______________________________________________ __________________________________________
Signature
Title
Telephone No. and Extension
TO CLAIMANT: READ IMPORTANT INSTRUCTIONS
AL RECLAMANTE: LEA LAS INSTRUCCIONES IMPORTANTES
FOR REQUESTING REVIEW ON REVERSE SIDE.
PARA SOLICITAR REVISION AL REVERSO DE ESTA FORMA.
DB-451 (3-99)
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