q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY
PART A - CLAIMANT'S STATEMENT (Please Print or Type) ANSWER ALL QUESTIONS
1. My name is....................................................................................................
2. Address................................................................................................................................................................
3. Tel. No.............................................. 4. Date of Birth ............................... 5. Married (Check one) qYes qNo
6. My disability is (if injury, also state how, when and where it occurred) ......................................................................
...........................................................................................................................................................................
7. I became disabled on ................................................................................ a. I worked on that day q Yes qNo
b. I have since worked for wages or profit. q Yes q 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.
9. My job is or was ..................................................................................................... .........................................
10. For the period of disability covered by this claim
a. Are you receiving wages, salary or separation pay: ...........................................................
b. Are you receiving or claiming:
(1) Workers' compensation for work-connected disability..................................................
(2) Unemployment Insurance Benefits.............................................................................
(3) Damages for personal injury .....................................................................................
(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 q received q claimed from ......................................... for the period ...................... to.........................
11. I have received disability benefits for another period or periods of disability within the 52 weeks immediately before
my present disability began ................................................................................................... q Yes q No
If "Yes", fill in the following: I have been paid by ..................................................From ................. To ....................
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.
Claim signed on ...................................................................................................................................................
If signed by other than claimant, print below: name, address, and relationship of representative.
..........................................................................................................................................................................
HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERSE
DB-450 (2-04)
First Middle Last
Date Claimant's Signature
Date Date
Occupation
Month Day Year
Number Street City or Town State Zip Code Apt. No.
Name of Union and Local Number, if Member
Date Date
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.
IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS,
CONTACT THE NEAREST OFFICE OF THE NYS WORKERS' COMPENSATION
BOARD, OR WRITE TO: WORKERS' COMPENSATION BOARD, DISABILITY
BENEFITS BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241-0005
SI TIENE DUDAS RELACIONADAS CON LA RECLAMACIÓN DE BENEFICIOS
POR INCAPACIDAD, COMUNIQUESE CON LA OFICINA MAS CERCANA DE LA
JUNTA DE COMPENSACIÓN OBRERA DE NUEVA YORK, O ESCRIBA A:
WORKER'S COMPENSATION BOARD, DISABILITY BENEFITS BUREAU, 100
BROADWAY- MENANDS, ALBANY, NY 12241-0005
Social Security Number
EMPLOYER'S DATES OF EMPLOYMENT
AVERAGE WEEKLY
WAGES
(Include Bonuses, Tips,
Commissions, Reasonable
Value of Board, Rent, etc.)
BUSINESS NAME BUSINESS ADDRESS TELEPHONE NO.
FROM THROUGH
Mo. Day Yr. Mo. Day Yr.
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 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
STATEMENT."
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.
MAKE A COPY OF THIS COMPLETED FORM FOR YOUR RECORDS BEFORE YOU SUBMIT IT.
1.
2.
3.
4.
5.
6.
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, www.wcb.ny.gov. It can be found under the heading Common Forms Online. Mail
the completed authorization form or letter to the address given below.
