Form Db450 - Notice And Proof Of Claim For Disability Benefits Page 2
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3P.O. Box 25339
New York State
Farmington, NY 14425
Phone 800-477-0087
NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
Use this form if you became disabled while employed or if you became disabled within four (4) weeks after termination of employment OR if you became
disabled after having been unemployed for more than four (4) weeks. Please answer all questions in Part A and questions 1 through 3 in Part B. Read all
instructions on this form carefully. Health care providers must complete Part B on page 2.
PART A - CLAIMANT'S INFORMATION
(Please Print or Type)
1. First Name:
Last Name:
MI:
2. Mailing Address:
Line 2:
Country:
City:
State:
Zip:
3. Daytime Phone #:
4. Email Address:
-
-
-
-
5. Social Security #:
6. Date of Birth:
7. Gender:
Male
Female
8. My disability is
:
(if injury, also state how, when and where it occurred)
/
/
9. I became disabled or became ineligible for Unemployment Insurance because of this disability on:
I worked on that day:
Yes
No
/
/
Have you recovered from this disability?
If Yes, what was the date you were able to work:
Yes
No
Have you since worked for wages or profit?
Yes
No
If Yes, list dates:
10. Give name of last employer. If more than one employer during last eight (8) weeks, name all employers. Average Weekly Wage is
based on all wages earned in last eight (8) weeks worked.
Average Weekly Wage
LAST EMPLOYER
PERIOD OF EMPLOYMENT
(Include Bonuses, Tips,
Commissions, Reasonable
Firm or Trade Name
Address
Phone Number
First Day
Last Day Worked
Value of Board, Rent, etc.)
Mo.
Day
Yr.
Mo.
Day
Yr.
Average Weekly Wage
OTHER EMPLOYER (during last eight (8) weeks)
PERIOD OF EMPLOYMENT
(Include Bonuses, Tips,
Commissions, Reasonable
Firm or Trade Name
Address
Phone Number
First Day
Last Day Worked
Value of Board, Rent, etc.)
Mo.
Day
Yr.
Mo.
Day
Yr.
Mo.
Day
Yr.
Mo.
Day
Yr.
11. My job is or was:
12. Union Member:
If "Yes":
Yes
No
Occupation
Name of Union or Local Number
13. Were you claiming or receiving unemployment prior to this disability?
Yes
No
If you did not claim or if you claimed but did not receive unemployment insurance benefits after LAST DAY WORKED, explain
reasons fully:
14. For the period of disability covered by this claim:
A. Are you receiving wages, salary or separation pay:
Yes
No
B. Are you receiving or claiming:
1. Workers' compensation for work-connected disability:
Yes
No
2. Paid Family Leave:
Yes
No
3. No-Fault motor vehicle accident
:
or personal injury involving third party
:
Yes
No
Yes
No
(check box)
(check box)
4. Long-term disability benefits under the Federal Social Security Act for this disability:
Yes
No
IF "YES" IS CHECKED IN ANY OF THE ITEMS IN 14, COMPLETE THE FOLLOWING:
/
/
/
/
I have:
received
claimed
from:
for the period:
to:
15. In the year (52 weeks) before your disability began, have you received disability benefits for other periods of disability?
Yes
No
/
/
/
/
If "Yes", fill in the following: Paid by:
from:
to:
16. In the year (52 weeks) before your disability began, have you received Paid Family Leave?
Yes
No
/
/
/
/
If "Yes", fill in the following: Paid by:
from:
to:
I hereby claim Disability Benefits and certify that for the period covered by this claim I was disabled. If my disability began while I was unemployed, I certify that I had been
unemployed for more than four (4) weeks. I have read the instructions on page 2 of this form and that the foregoing statements, including any accompanying statements are, to the
best of my knowledge, true and complete.
Date
Claimant's Signature
An individual may sign on behalf of the claimant only if he or she is legally authorized to do so and the claimant is a minor, mentally incompetent or incapacitated. If signed by
other than claimant, print information below and complete and submit Form OC-110A, Claimant's Authorization to Disclose Workers' Compensation Records.
On behalf of Claimant
Address
Relationship to Claimant
DB-450 (9-17) Page 1 of 2
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