Notice And Proof Of Claim For Disability Benefits Form
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1
2NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY
1. USE THIS FORM ONLY IF YOU BECOME SICK OR DISABLED WHILE EMPLOYED OR IF YOU BECOME SICK OR DISABLED WITHIN FOUR (4)
WEEKS AFTER TERMINATION OF EMPLOYMENT. USE GREEN CLAIM FORM DB-300 IF YOU BECOME SICK OR DISABLED AFTER HAVING
BEEN UNEMPLOYED MORE THAN FOUR (4) WEEKS.
2. YOU MUST COMPLETE ALL ITEMS OF PART A - THE :CLAIMANT'S STATEMENT.: BE ACCURATE CHECK ALL DATES.
3. BE SURE TO DATE AND SIGN YOUR CLAIM (SEE ITEM 12). IF YOU CANNOT SIGN THIS CLAIM FORM, YOUR REPRESENTATIVE MAY SIGN IN
YOUR BEHALF. IN THAT EVENT, THE NAME, ADDRESS, AND REPRESENTATIVES RELATIONSHIP TO YOU SHOULD BE NOTED UNDER THE
SIGNATURE
4. DO NOT MAIL THIS CLAIM UNLESS YOUR HEALTH CARE PROVIDER COMPLETES AND SIGNS PART-B - THE "HEALTH CARE
PROVIDER'S STATEMENT.
5. YOUR COMPLETED CLAIM SHOULD BE MAILED WITHIN THIRTY (30) DAYS AFTER YOU BECOME SICK OR DISABLED TO YOUR LAST
EMPLOYER OR YOUR LAST EMPLOYER'S INSURANCE COMPANY.
6. MAKE A COPY OF THIS COMPLETED FORM FOR YOUR RECORDS BEFORE YOU SUBMIT IT.
PART A - CLAIMANT'S STATEMENT (Please print or type) ANSWER ALL QUESTIONS
Tel No
2. My age is
1. My name
First
Middle
Last
3. Address
Number
Street
City or Town
State
Zip
Apt #
5. Married (Check 1) Yes
No
4. May Social Security Number
6. My Disability is (if injury, also state how, when and where it occurred)
7. I became disabled
a. I worked that day (Yes)
(No)
Month
Day
Year
Yes
No
If Yes give dates
b. I have since worked for wages or profit
8. Give name of last employer. If more than one employer during last eight (8) weeks, name all employers.
Employer's
Dates of Employment
Avg Weekly Wages
From
Through
Mo
Includes Bonuses, Tips, Commissions,
Business Address
Telephone No
Business Name
Mo Day Yr
Day Yr
Reasonable Value of Board, Rent, etc
9. My Job is or was
Occupation
Name of Union & Local no if member
10. For the period of disability covered by this claim
Yes
No
a. Are you receiving wages, salary or separation pay:
b. Are you receiving or claiming
Yes
No
(1) Workers' compensation for work-connected disability
Yes
No
(2) Damages for personal injury
Yes
No
(3) Unemployment Insurance Benefits
Yes
No
(4) Disability Benefits under the Federal Social Security Act
If "yes" is checked in any of the items a, b(1), b(2), b(3), b(4), fill in the following:
I have
Received
or
Claimed from
For the Period----- From
To
Date
Date
11. I have received disability benefits for another period or periods of disability within the 52 weeks immediately
Yes
No
before my present disability began
12. I have read the instructions above. I hereby claim Disability Benefits and certify that for the period covered by this claim I
was disabled; and that the foregoing statements, including any accompanying statements, are to the best of my
knowledge true and complete
Sign Claim signed on
Date
Claimants Signature
If signed by other than claimant, print below: name, address and relationship of representative
Name and Address
Relationship
IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS, CONTACT THE NEAREST OFFICE OF THE NEW YORK STATE
WORKERS' COMPENSATION BOARD, OR WRITE TO: WORKERS' COMPENSATION BOARD, DISABILITY
BENEFITS BUREAU, 100 BROADWAY - MENANDS, ALBANY, NY 12241
HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERSE SIDE
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY FILES A
X
STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME
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