Db-450 Form - Notice And Proof Of Claim For Disability Benefits Page 2
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1
2THE UNITED STATES LIFE
Insurance Company
SUBMIT TO:
THE MAXON COMPANY
P.O. BOX 606
Notice and Proof of Claim for Disability Benefits
NEVERSINK, NY 12765
CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY
1.
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 GREEN CLAIM FORM DB-300 IF YOU BECOME SICK OR DISABLED AFTER HAVING
BEEN EMPLOYED 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
IT IN YOUR BEHALF. IN THAT EVENT, THE NAME, ADDRESS AND REPRESENTATIVE'S 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
1. My name is
Social Security Number
First
Middle
Last
2. Address
Number
Street
City or Town
State
Zip Code
Apt. No.
5. Married (Check one) ❑ Yes ❑ No
3. Tel. No.
4. My age is
6. My disability is (if injury, also state how, when and where it occurred)
a. I worked on that day ❑ Yes
❑ No
7. I became disabled on
Month
Day
Year
❑ Yes
❑ No
b. I have since worked for wages or profit.
If "Yes", give dates
8. Give name of last employer. If more than one employer during the last eight (8) weeks, name all employers.
AVERAGE WEEKLY
EMPLOYER'S
DATES OF EMPLOYMENT
WAGES
FROM
THROUGH
(Include Bonuses, Tips,
BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
Commissions, Reasonable
Mo.
Day
Yr.
Mo.
Day
Yr.
Value of Board, Rent, etc.)
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
❑ 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) Unemployment Insurance Benefits
❑ Yes
❑ No
(3) Damages for personal injury
❑ Yes
❑ No
(4) Benefits under the Federal Social Security Act for long-term disability
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
❑ Yes
❑ No
my present disability began
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
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's Signature
If signed by other than claimant, print below; name, address, and relationship of representative.
SI TIENE DUDAS RELACIONADAS CON LA RECLAMACIÓN DE BENFICIOS
IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS,
POR INCAPACIDAD, COMUNIQUESE CON LA OFICINA MAS CERCANA DE
CONTACT THE NEAREST OFFICE OF THE NYS WORKERS' COMPENSATION
LA JUNTA DE COMPENSACIÓN OBRERA DE NEUVA YORK, O ESCRIBA A:
BOARD, OR WRITE TO: WORKERS' COMPENSATION BOARD, DISABILITY
WORKER'S COMPENSATION BOARD, DISABILITY BENEFITS BUREAU, 100
BENEFITS BUREAU, 100 BROADWAY-MENANDS, ALBANY, , NY 12241-0005
BROADWAY-MENANDS, ALBANY, NY 12241-0005
DB-450 (11-98)
HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERSE
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