Notice And Proof Of Claim For Disability Benefits Form Page 2

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NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
IMPORTANT: USE THIS FOR 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 GREEN CLAIM FORM db300.
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 RECEIPT OF THE FORM.
For item 7-d give approximate date. Make some estimate. If disability is caused by or arising in connection with pregnancy, enter estimated delivery ate under "Remarks
1. Claimant's Name
Age______ 3. Male
First
Middle
Last
Female
4. Diagnosis/Analysis
a. Claimant's Symptoms:
b. Objective Findings:
5. Claimant Hospitalized?
Yes_____ No______
6. Operation Indicated
Yes_____ No______
7. Enter Dates for the Following
Mo
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 a result of injury arising out of and in the course of employment or occupational
disease? Yes_____ No______
If "Yes" has Form C4/48 been filled with the Workers' Compensation Board?
Yes_____ No______
Remarks (Attach additional sheet if necessary)
9. I affirm that I am a ___________________Licensed or Certified in the State of _______License No._________________
Health care provider's Signature _____________________________________
Date_______________________
Health Care Provider's Name (Please Print)______________________________________Tel No______________________
Office Address ________________________________________________________________________________________
Number
Street
City or Town
State
Zip Code
PART C - EMPLOYER'S STATEMENT
IMPORTANT-Indicate percentage employer contributes to premium _________%
1. Employee's Name _______________________________________________________
2. Employee's Address ____________________________________________________Policy No e-910-______________
3. Employee's Occupation _______________________Date employed ______________ SS Number ______________
4. Full Time _______ Part time ________Check usual days worked Mon
Tues
Wed
Thurs
Fri
Sat
Sun
5. Is claimant: an employee ____owner____partner____high school student____employer's spouse _____
6. Date employee last worked.______________________________
Earnings for 8 weeks prior to disability Including the week disability began
7. Date employees returned to work ________________________
Month
Day
Year
No dys workedAmount
8. Date employee's wages ceased or will cease ______________
.
9. Are wages being continued during disability?_______________
10. If yes, is reimbursement requested?_____________________
11. On what date did you receive the completed claim form?
12. Did the disability occur as a result of employment Yes___No___
13. Name and address of your compensation carrier___________
14. Is employee a member of a union which provides NY State
Total
disability benefits?_____________________
0
15. Do you expect to rehire ____________
Indicate weekly value of board
16. If employee is no longer in your employ, check reason
Lodging and tips
Labor dispute ___ Lack of work ___ Fired___ Quit___.
Mail Completed Form
17. Has the claimant received UI Benefits? Yes--- No---
DIOCESE OF BUFFALO
If yes, give dates:________________________________
INSURANCE SERVICE DEPT.
Employer's name_______________________________
795 MAIN ST
Address_____________________________________
BUFFALO, NY 14203
Date ______________Telephone __________________
PHONE # 716-847-8396
Signed by _________________________ Title_________________

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