Form Db-451 - Notice Of Total Or Partial Rejection Of Claim For Disability Benefits Page 2
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2CLAIMANT'S REQUEST FOR REVIEW
MAIL TO :
WORKERS' COMPENSATION BOARD
DISABILITY BENEFITS BUREAU
100 BROADWAY-MENANDS
ALBANY, NY. 12241-0005
I acknowledge receipt of Notice of Rejection of my claim for Disability Benefits. I hereby request a review of the
rejection of such claim for the following reasons: (Give complete details).
Acuso recibo de la notificacion de denagacion de mi reclamacion de beneficios por incapacidad. Solicito una revision
de dicha decision, por las siguientes razones: (De detalles completos).
________________________________________________________________________________________________
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Social Security No.________________________ Telephone Number________________________________________
Date___________________________ Claimant's Signature________________________________________________
INSTRUCTIONS TO CLAIMANT
INSTRUCCIONES AL RECLAMANTE
1.
Si no está conforme con este rechazo de su reclamación,
If you do not agree with this rejection of your claim,
1.
complete este documento. Usted debe mandar su Aviso de
complete the above statement. You should file your
Rechazo antes de 26 semanas.
Request for Review within 26 weeks.
2.
De usted las razones ESPECIFICAS que le hacen solicitar
Give SPECIFIC reasons for requesting a review for each
2.
revisión, con respecto a cada punto de rechazo chequeado en
item of rejection checked on the face of this form.
el frente de este formulario.
Attach any medical evidence, employment records, and/or
3.
Adjunte a esta formulario Certificados Médicos, Antecedentes
3.
de Empleo y Desempleo y/o cualquier otro documento que
any other evidence, which you feel will support your
usted entienda hayan de apoyar su solicitud de revisión.
request for review.
4.
Usted puede solicitar que la presentación tardía de su
You may request that late filing be excused by the Chair,
4.
reclamación le sea disculpada por la Presidencia (Chair) de la
Workers' Compensation Board, if it was not reasonably
Junta de Compensacion Obrera, si a usted no le fue
possible to file within 30 days after disability began and
razonablemente posible presentar su reclamación dentro de los
filing was done as soon as possible.
30 dias desde la fecha del comienzo de su incapacidad y si
Complete all copies of this form received from your
hizo dicha presentación
lo mas pronto que le fue posible
5.
hacerlo.
employer or insurance company.
5.
Complete ambas copias de esta forma.
Mail two copies PROMPTLY to the above address.
6.
6.
Envíe por correo, PRONTAMENTE, dos copia a la dirección
indicada ariba.
DB-451 (3-99) Reverse
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