Form Db-450 - Notice And Proof Of Claim For Disability Benefits

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NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY
WITHIN FOUR (4) WEEKS AFTER
1. USE THIS FORM IF YOU BECOME SICK OR DISABLED WHILE EMPLOYED OR IF YOU BECOME SICK OR DISABLED
TERMINATION OF EMPLOYMENT.
DB-300
BECOME SICK OR DISABLED AFTER HAVING BEEN UNEMPLOYED MORE
USE CLAIM FORM
IF YOU
THAN FOUR (4) WEEKS.
"CLAIMANT'S STATEMENT"
.
2. YOU MUST COMPLETE ALL ITEMS OF PART A - THE
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 IT IN 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 COMPLETES AND SIGNS PART B - THE "HEALTH CARE PROVIDER'S
4.
STATEMENT."
WITHIN THIRTY (30) DAYS AFTER YOU BECOME SICK OR DISABLED TO YOUR LAST EMPLOYER
5. YOUR COMPLETED CLAIM SHOULD BE MAILED
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
Social Security Number
1. My name is .............................................................................................................
First
Middle
Last
2. Address.................................................................................................................................................................
Number
Street
City or Town
State
Zip Code
Apt. No.
3. Tel. No.......................................
4. Date of Birth...........................
5. Married (Check one)
Yes
No
6. My disability is (if injury, also state how, when and where it occurred) ............................................................................
.........................................................................................................................................................................................
Yes
7. I became disabled on .....................................................................
a. I worked on that day
No
Month
Day
Year
Yes
b. I have since worked for wages or profit.
No If "Yes", give dates ..............................................................
8. Give name of last employer. If more than one employer during the last eight (8) weeks, name all employers.
DATES OF EMPLOYMENT
EMPLOYER'S
AVERAGE WEEKLY WAGES
(Include Bonuses, Tips, Commissions,
FROM
THROUGH
BUSINESS ADDRESS
TELEPHONE NO.
BUSINESS NAME
Reasonable Value of Board, Rent, etc)
Mo.
Day
Yr.
Mo.
Day
Yr.
9. My job is or was ...................................................................................................
...................................................
Occupation
Name of Union and Local Number, if Member
10. 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:
Yes
(1) Workers' compensation for work-connected disability..................................................................................
No
(2) Unemployment Insurance Benefits..............................................................................................................
Yes
No
(3) Damages for personal injury.......................................................................................................................
Yes
No
Yes
(4) Benefits under the Federal Social Security Act for long-term disability.........................................................
No
IF "YES" IS CHECKED IN ANY OF THE ITEMS IN 10a OR 10b, COMPLETE THE FOLLOWING:
I have
received
claimed from .............................................. for the period ......................... to .......................
Date
Date
11. I have received disability benefits for another period or periods of disability within the 52 weeks immediately before my
present disability began .............................................................................................................
Yes
No
If "Yes", fill in the following: I have been paid by ................................................... From ...................... To ....................
Date
Date
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.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR
BELEIF 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's Signature
If signed by other than claimant, print below: name, address, and relationship of representative.
.....................................................................................................................................................................................
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 Worker's 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, www.
wcb.state.ny.us. It can be found under the heading Common Forms Online. Mail the completed authorization form or letter to the address given below.
SI TIENE DUDAS RELACIONADAS CON LA RECLAMACION DE BENEFICIOS POR INCAPICIDAD,
I
F YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS,
CONTACT THE NEAREST OFFICE OF THE NYS WORKERS' COMPENSATION
COMUNIQUESE CON LA OFICINA MAS CERCANA DE LA JUNTA DE COMPENSACION OBRERA
BOARD, OR WRITE TO: WORKERS' COMPENSATION BOARD, DISABILITY
DE NUEVA YORK, O ESCRIBA A : WORKER'S COMPENSATION BOARD, DISABILITY BENEFITS
BENEFITS BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241-0005
BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241-0005
DB-450 (2-04)
HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERSE

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