Form Db450 - Notice And Proof Of Claim For Disability Benefits printable pdf download

NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS

CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY

Use this form if you become sick or disabled while employed or if you become sick or disabled within four (4)weeks after termination of employment. Use claim form DB-300

if you become sick or disabled after having been unemployed more than four (4) weeks.

You must complete all items of Part A - The "CLAIMANT'S STATEMENT". Be accurate. Check all dates.

Be sure to date and sign your claim (see item 12). If you cannot sign this form, your repr esentative may sign it on your behalf. In that event, the name, address

and representative's relationship to you should be noted under the signature.

DO NOT MAIL THIS CLAIM UNLESS YOUR HEALTH CARE PROVIDER COMPLETE'S AND SIGNS PART B - THE "HEALTH CARE PROVIDER'S STATEMENT".

Your completed claim should be mailed WITHIN 30 DAYS after you become sick or disabled, to your last employer or your last employer's insurance company.

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

Social security number

1. NAME

First

Middle

Last

ADDRESS

Number

Street

City or Town

State

Zip Code

Apartment Number

3a.

TEL# (

)

Age

Married (Check one)

Yes

ADDRESS

My disability is (if injury, also state HOW , WHEN , and WHERE it occurred)

7a.

I became disabled on

I worked that day (Check one)

Yes

Month

Day

Year

I have since worked for wages or profit.

If "Yes" give dates:

7b.

Yes

GIVE NAME OF LAST EMPLOYER. IF MORE THAN ONE EMPLOYER DURING THE LAST EIGHT (8) WEEKS, NAME ALL EMPLOYERS.

Average Weekly Gross Wages

Dates of Employment

EMPLOYERS

(Include Bonuses, Tips,

FROM

THROUGH

Commissions, Reasonable

BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

Mo. Day Year

value of Board, Rent, Etc)

My job is or was (Occupation)

Name of Union and Local Number,

if member

For the period of Disability covered by this claim:

10.

Yes

Are you receiving wages, salary, or separation pay? ……………………………………………………………………………….....

Are you receiving or claiming :

Yes

Workers' Compensation for work-connected disability ………………………………………………………………………….....

Yes

Unemployment Insurance Benefits ……………………………………………………………………………………………….….

Damages for personal injury ……………………………………………………………………………………………………….....

Yes

Benefits under the Federal Social Security Act for long-term disability …………………………………………………….……

Yes

IF "YES" IS CHECKED IN ANY OF THE ITEMS IN 10a OR 10b, COMPLETE THE FOLLOWING:

I have

received

claimed from:

for the period:

I have received disability benefits for another period or periods of disability within the 52 weeks immediately before

11.

Yes

my present disability began……….....................................................................................................................................................

If "Yes", fill in the following: I have been paid by

from

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

12.

forgoing statements, including any accompanying statements, are to the best of my knowledge true and complete.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE

OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL

STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.

CLAIM SIGNED ON:

Date:

Claimant Signature:

If signed by other than claimant, PRINT below: name, address, and relationship of representtive.

Disclosure of Information: The Board will not disclose any information about your case to any unauthorized party without your consent. If you choose to have such information

disclosed to an unauthorized party, you must file with the Board an original signed form OC-110A, Claimant's Authorization to Disclose Workers' Compensation Records, or an

original signed, notarized authorization letter. You may telephone your local WCB office to have form OC-110A sent to you, or you may download it from our web page,

It can be found under the heading Common Forms Online. Mail the completed authorization form or letter to the address given below.

SI TIENE DUDASRELACIONADAS CON LA RECLA ACION DE BENEFICIOS POR INCAPACIDAD,

IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS, CONTACT THE NEAREST

COMUNIQUSE CON LA OFINCINA MAS CERCANA DE LA JUNTA DE COMPENSACION OBRERA DE NUEVA

OFFICE OF THE NYS WORKERS' COMPENSATION BOARD, OR WRITE TO: WORKERS' COMPENSATION

YORK O ESCRIBA A: WORKERS' COMPENSATION BOARD, DISABILITY BENEFITS BUREAU, 100

BOARD, DISABILITY BENEFITS BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241-0005

BROADWAY-MENANDS, ALBANY, NY 12241-0005

HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERSE

DB450 (09/12)

Standard Security Life Insurance Company of New York P. O. Box 25339

Farmington, New York 14425