Fillable Prepare. Protect. Prevail. ith Completion of DB 450 (The Hartford)

Fill Online, Printable, Fillable, Blank Prepare. Protect. Prevail. ith Completion of DB 450 (The Hartford) Form

Use Fill to complete blank online THE HARTFORD pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Prepare. Protect. Prevail. ith Completion of DB 450 (The Hartford)

On average this form takes 52 minutes to complete

The Prepare. Protect. Prevail. ith Completion of DB 450 (The Hartford) form is 6 pages long and contains:

  • 0 signatures
  • 9 check-boxes
  • 202 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your The Hartford forms online.

BROWSE THE HARTFORD FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Prepare. Protect. Prevail.
®
Important Information to Assist w
ith Completion of DB 450 Claim Form - Part C
Valued Customer:
There are two sections of the DB 450 Claim Form (Employer Section Part C) where clarification may be helpful. We
hope this document will aid in completion of the claim form.
Requesting Reimbursement:
In the Employer Section (Part C) of the DB 450 Claim form, we ask if wages were paid during the disability period,
and whether or not the employer wishes to be reimbursed by The Hartford.
Article 9 (NY DBL Law) § 237 of the New York Workers’ Compensation Law states an employer, may be reimbursed
by the New York DBL carrier during a claim for any time the employer has advanced monies to the claimant if the
claim for reimbursement is filed with the carrier prior to payment of benefits by the carrier. Here are some items for
your consideration when determining whether or not to be reimbursed by The Hartford:
Advancement of monies by the employer must be employer sponsored monies.
Vacation and PTO time are not considered employer sponsored, but instead are considered employee
earned time thus not a reduction to DBL benefits nor a basis for reimbursement.
Salary continuation and sick time are considered employer sponsored and are reimbursable by The
Hartford.
Reimbursement of benefit money to the employer allows the employer to continue salary, and withhold the
appropriate FICA taxes.
Reimbursed funds from The Hartford are payable to the employer and taxes are not withheld.
When requesting reimbursement, be sure to include the entire period of time that reimbursement is
requested should the claim extend to full duration of New York DBL.
For more information, please visit: http://www.wcb.ny.gov/content/main/offthejob/IntroToLaw_DB.jsp
Taxability of Benefits:
Please see the below excerpt from IRS Publication 15A to assist you in calculating the taxable percent of benefits.
Taxability is expected to be less than 100 percent when the employee is contributing to the cost of the coverage.
Excerpt from IRS Publication 15A, Page 17 and 18: Group policy. If both the employer and the employee
contributed to the sick pay plan under a group insurance policy, figure the taxable sick pay by multiplying total sick
pay by the percentage of the policy's cost that was contributed by the employer for the 3 policy years before the
calendar year in which the sick pay is paid. If the policy has been in effect fewer than 3 years, use the cost for the
policy years in effect or, if in effect less than 1 year, a reasonable estimate of the cost for the first policy year.
Example. Alan is employed by Edgewood Corporation. Because of an illness, he was absent from work for 3 months
during 2015. Key Insurance Company paid Alan $2,000 sick pay for each month of his absence under a policy paid
for by contributions from both Edgewood and its employees. All of the employees' contributions were paid with after-
tax dollars. For the 3 policy years before 2015, Edgewood paid 70% of the policy's cost and its employees paid 30%.
Because 70% of the sick pay paid under the policy is due to Edgewood's contributions, $1,400 ($2,000 × 70%) of
each payment made to Alan is taxable sick pay. The remaining $600 of each payment that is due to employee
contributions is not taxable sick pay and is not subject to employment taxes. Also, see Example of Figuring and
Reporting Sick Pay, later in this section.
For more information please visit: https://www.irs.gov/pub/irs-pdf/p15a.pdf
LC-5012-20 DB-450 Page 1 of 7 02/2018
NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
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
UNEMPLOYED 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 15). IF YOU CANNOT SIGN THIS FORM, YOUR REPRESENTATIVE MAY SIGN IT ON 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 The Hartford P. O. Box 14869 Lexington, KY 40512-4869 Fax 1-833-357-5153.
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: (First, Middle & Last)
Month/Day/Year Month/ Day/Year
( )
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
(
(
(
)
)
)
Month/ Day/ Year
Y PE
2. Social
Security Number:
3. Date of Birth:
4.
Marital Status
Married
Single
5. My Address :
(
Number, Street, City or Town, State & Zip Code) 6
. My disability is
:
(if injury, also state how, when and where it occurred)
7. My Telephone Number:
8. E-Mail Address: (E-Mail is used to provide The Hartford At Work registration instructions and important status updates.)
9.
I became disabled on :
a. I worked on that day: Yes No b. I have since worked for wages or profit: Yes No
If "Yes", give dates:
10.
.
Give name of last employer. If more than one employer during the last eight (8) weeks, name all employers.
Employer's
Business Name Business Address Phone Number
Dates of Employment
From Through
Average Weekly Wages
(Include Bonuses, Tips,
Commissions, Reasonable
Value of Board, Rent, etc.)
11. My job is or was: (Occupation) 12. Name of Union and Local Number, if member
13. 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) Unemployment Insurance Benefits
Yes No
(3) Paid Family Leave
Yes No
(4) Damages for personal injury
Yes No
(5) Benefits under the Federal Social Security Act for long-term disability
Yes No
IF "YES" IS CHECKED IN ANY OF THE ITEMS IN 13a OR 13b, COMPLETE THE FOLLOWING
I have received claimed From For the period
To
14a.
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:
14b.
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:
15. 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.
AN RSON 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 FINES AND IMPRISONMENT.
Electronic Funds Transfer (EFT) is our standard method of payment. When making our claim decision we may contact you to obtain your
banking information.
Claim signed on: Claimant's Signature:
If signed by other than claimant, print below: name, address,
and relationship of representative:
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
E
LC-5012-20 DB-450
HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERS
Page 2 of 7
02/2018
/
/
/
/
/
/
/
/
Clear Form
NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
IMPORTANT: USE THIS FORM ONLY WHEN THE CLAIMANT BECOMES SICK OR DISABLED WHILE EMPLOYED OR BECOMES SICK OR
DISABLED WITHIN FOUR (4) WEEKS AFTER TERMINATION OF EMPLOYMENT. OTHERWISE USE GREEN CLAIM FORM DB-300.
PART B - HEALTH CARE PROVIDER'S STATEMENT (Please Print or Type)
THE HEALTH CARE PROVIDER'S STATEMENT MUST BE FILLED IN COMPLETELY AND THE FORM MAILED TO THE INSURANCE
CARRIER OR SELF-INSURED EMPLOYER, OR RETURNED TO THE CLAIMANT WITHIN SEVEN DAYS OF THE RECEIPT OF THE FORM.
( )
7.
6.
a.
For item 7d, give approximate date. Make some estimate. If disability is caused by or arising in connection with pregnancy,
enter estimated delivery date under "Remarks". (Even if considerable question exists, estimate date. Avoid using terms
such as unknown or undetermined).
The Hartford
P. O. Box 14
Lexington, KY 40512-4
Fax 1-8--53
1. Claimant's Name: 2. Date of Birth: 3. Sex:
Male Female
4. Diagnosis/Analysis:
a. Claimant's Symptoms:
Diagnosis Code:
b. Objective Findings:
5. Claimant Hospitalized? Yes No
From To
Operation Indicated? Yes No
a. Type b. Date
Enter Dates for the Following:
Date of your first treatment for this disability:
b. Date of your most recent treatment for this disability:
c. Date claimant was unable to work because of this disability:
d. Date claimant will be able to perform usual work:
e. If disability is pregnancy related, please estimate delivery date:
8.
In your opinion, is this disability the result of injury arising out of and in the course of employment or occupational disease?
Yes No
If "Yes", has form C-4 been filed with the Workers'
Compensation Board? Yes No
Remarks: (attach additional sheet, if necessary)
I affirm that I am a: Chiropractor Physician Psychologist
Dentist Podiatrist Nurse-Midwife
License Number:
Licensed in the State of:
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 FINES AND IMPRISONMENT.
Health Care Provider's Signature: Date:
Health Care Provider's Name: (Please Print)
Telephone Number:
Office Address:
(Number, Street , City or Town, State & Zip)
HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a (4) (a) and 12 NYCRR 325-1.3 require health care
providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these
legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information.
LC-5012-20 DB-450 Page 3 of 7 02/2018
NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
The Hartford
P. O. Box 14
Lexington, KY 40512-4
Fax 1-8--53
PART C - EMPLOYER'S STATEMENT
Employee's full name: (As shown on Social Security Card)
f "
)
I
I
B
b
th
Social Securit y Number:
Employee's Address: (Street, City, State & Zip Code) Date of Birth:
Date of employment:
Full Time Part Time
Check days normally worked:
Sun. Mon. Tues. Wed. Thurs. Fri. Sat.
If Part Time, give particulars:
I
I
s employee a Union member?
Yes No
If "Yes," is employee entitled to Union Benefits
Yes No
Occupation:
Date employee last worked:
Date employee returned to work:
Were wages continued during disability?
Yes No
Were wages Sick pay?
Yes No From: To:
Were wages Vacation pay?
Yes No
From To
s reimbursement requested?
Yes No
I
I
I
s disability due to job?
Y
es No
f "Yes," has a compensation claim been filed?
Yes No
ndicate Weekly Value of Board, Lodging and Tips:
s this employee currently covered by Social Security?
Yes No
If "No," state grounds for exemption:
EARNINGS 8 WEEKS PRIOR TO AND INCLUDING THE DATE
LAST WORKED PRIOR TO THE ONSET OF DISABILITY.
No. Days
Month Day Year Worked Amount
Total
s employee enrolled in a Hartford Long Term Disability Plan?
Yes No I Yes," effective date. Hartford NY Disability Policy Number:
ased on the employer/employee premium contributions made over the last 3 years, what percentage of the Weekly Disability
enefit it is considered taxable? % LTD % (See section 6 of IRS Publication 15-A for information on determining
e taxable percentage.) (If blank, we will code the benefit as 100% taxable until you submit written notice of the correct taxable %.)
Employer's Name: Employer's Identification Number:
Address: (Street, City, State & Zip Code) Telephone Number:
(
Signed by: Date: Title:
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
LC-5012-20 DB-450 Page 4 of 7 02/2018
Signature - Please read the statement that applies to your state of residence and sign the bottom of the second page.
With the exception of any source(s) of income reported above in this form, I certify by my signature that I have not received and am
not eligible to receive any source of income, except for my disability benefits from this plan. Further, I understand that should I
receive income of any kind or perform work of any kind during any period The Hartford has approved my disability claim, I must
report all details to The Hartford, immediately. If I receive disability income benefits greater than those which should have been
paid, I understand that I will be required to provide a lump sum repayment to the Plan. The Hartford has the option to reduce or
eliminate future disability payments in order to recover any overpayment balance that is not reimbursed.
For residents of all states EXCEPT Arizona, Alabama, California, Colorado, Florida, Kentucky, Maine, Maryland, New
Jersey, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Tennessee, Virginia and Washington: Any
person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
For Residents of Arizona: For your protection Arizona law requires the following statement to
appear on this form. Any person who knowingly presents a false or fraudulent claim for payment
of a loss is subject to criminal and civil penalties.
For Residents of Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines
or confinement in prison, or any combination thereof.
For Residents of California: For your protection, California law requires the following to appear on this form: Any person who
knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
For residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,
fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides
false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to
defraud the policyholder or claimant with regard to a settlement award payable from insurance proceeds shall be reported to the
Colorado Division of Insurance within the Department of Regulatory Agencies.
For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of
claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
For residents of Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a
statement of claim or an application for insurance containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
For residents of Maine, Tennessee, and Washington: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and
denial of insurance benefits.
For Residents of Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or
benefit and who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
For residents of New Jersey: Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties. Any person who includes any false or misleading information on an
application for insurance policy is subject to criminal and civil penalties.
For residents of New York: Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also
be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
For residents of Ohio: Any person who, with intent to defraud or knowing he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
For residents of Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer,
makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a
felony.
For residents of Oregon: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto that the insurer relied upon is subject to a denial and/or reduction in
insurance benefits and may be subject to any civil penalties available.
LC-5012-20 DB-450 Page 5 of 7 02/2018
Signature - Please read the statement that applies to your state of residence and sign the bottom of the page.
For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information or conceals for the purpose
of misleading, information concerning any fact material hereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties.
)RUUHVLGHQWV RI3XHUWR5LFR: Any person who knowingly and with the intention of defraudi
ng presents false information in an
insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other
benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be
sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars
($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present,
the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
)RUUHVLGHQWV RI9LUJLQLD: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement may have violated the state law.
The statements contained in this form are true and complete to the best of my knowledge and belief.
LC-5012-20 DB-450 Page 6 of 7 02/2018
Signature Date
Electronic Funds Transfer (EFT) is our standard method of payment. When making our claim decision we may contact you
to obtain your banking information.
STATEMENT OF RIGHTS
NEW YORK STATE DISABILITY BENEFITS
ANDREW M. CUOMO, Governor
IF YOU ARE UNABLE TO WORK BECAUSE OF A NON-OCCUPATIONAL
ILLNESS OR INJURY, YOU MAY BE ENTITLED TO DISABILITY BENEFITS
1.
Your employer is required by law to provide for the payment of disability benefits to hi
s/her employees.
2.
Statutory disability benefits are payable for any non-work related injury or illness (including disability due to pregnancy)
beginning with the 8th consecutive day of disability. Benefits are payable for up to 26 weeks. The to
tal amount of
combined pai
d family and disability leave an employee
may take in a 52 consecutive week period may not exceed
26weeks. Ben
efit payments are based on your average weekly wages for the eight wee
ks immediately prior to your
disability, and
are subject to the maximum allowable by the law in effect on the initial day of disability. Your employ
er or
union may provide for different benefits
which are at least as favorable
as statutory benefits under an approved Disability
Benefits
Plan or
Agreement.
3.
TO CLAIM BENEFITS you should file written notice and proof of disability (Claim Form DB-450) wit
h your employer or the
insurance carrier named below
within 30 days from the first day of your disability, or a
ll or part of your claim may be
rejected. In no event should
you wait more than 26 weeks from that date to file a claim. You may o
btain Form DB-450from
your employer, its insurance
carrier, your health care provider or by contacting the Workers' Compensation Boar
d. (See
address and telephone number below
.) Do not assume that your employer has filed a claim on your behalf;
claim filing
is y
our responsibility.
4.
You are entitled to be treated by any physician, chiropractor, dentist, nurse-midwife, podiatrist or psychologist of your
choice. Unlike workers' compensation, your medical bills will not be paid by your employer or the insurance carrier, unless
your employer and/or union provides for the payment of medical bills under an approved Disabil
ity Benefits Plan
or
Agreement.
5.
Disability benefits are to be paid directly to you by the insurance carrier, not through your employer, unless yo
ur
employer is an approved self-insurer.
6.
If
your employer or the insurance carrier contends that you are not entitled to the payment of disability
benefits,
they
are required to send you a Notice of Rejection, wi
thin 45 days of the filing of your claim, telling y
ou the
r
easons benefits are not being paid. If you disagree with their rejection, you have a legal right to request a review
of the rejection by the Workers' Compensation Board. IMPORTANT: If within 45 days of filing your claim you do
not
receive benefits and do not receive a Notic
e of Rejection (Form DB-451), promptly contact the Workers' Compens
ation
Board at the telephone number below.
7.
If
your disability is the result of an automobile accident and you have filed a claim for no-fault benefits, you
must also
file a claim (Form DB-450) for disability be
nefits. If you do not file for disability benefits, the no
-fault insurer may
reduce your no-fault payments. IMPORTANT: In such cases, if you are not entitled to disability
benefits, immediately
advise the no-
fault insuranc
e carrier.
8.
Your employer may not ask you to waive your right to disability benefits nor may your employer deduct more than 60cents
a w
eek (unless the additional contribution is part of an approved plan) from your pay to contribute to
the payment of
disability bene
fits insurance premiums. You cannot be discharged or discriminated against fo
r filing a claim for
disability
bene
fits.
IF YOU HAVE DIFFICULTY IN OBTAINING A CLAIM FORM OR NEED HELP IN FILLING IT OUT, OR IF YOU HAVE ANY OTHER
QUESTIONS OR PROBLEMS ABOUT A NON-WORK RELATED INJURY OR ILLNESS, CONTACT ANY OFFICE OF THE WORKERS'
COMPENSATION BOARD.
This information is a simplified presentation of your rights as required by Section 229 of the
Disability and Paid Family Leave Benefits Law. Your employer's disability benefits
insurance carrier is:
The Hartford
P. O. Box 14
Lexington, KY 40512-4
Fax 1-8--53
Prescribed by the Chair,
Workers' Compensation Board
DB-271S (11-17) NYS Workers' Compensation Board•PO Box 5205, Binghamton, NY 13902-5205
Customer Service: (877) 632-4996
•www.wcb.ny.gov
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Prepare. Protect. Prevail. ith Completion of DB 450 (The Hartford)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document