Proof of Coverage Disability Benefits
DB 820/829 Web Submission
Instructions For Submission of DB820/829 Form
- SELECT THE TRANSACTION TYPE (INITIAL, CANCELLATION, REINSTATEMENT, SUPERCEDES) AND TRANSACTION EFFECTIVE DATE
A separate filing is necessary for each transaction type desired. The Transaction Effective Date is the date you want the transaction to be effective NOT the date the form is completed.
1/2. INSURER/CARRIER NAME
This is the name of the carrier/insurer assuming the employer's financial responsibility for Disability Benefits claims. Based on the OFT sign-on, the insurer/carrier name will either 1.) pre-fill with the name, or 2.) if there are more than one name, choose the correct name from the drop down list.
6. RECEIVED DATE
7. WCB EMPLOYER NUMBER
The WCB will be assigning its own employer identification number to each employer name. Once a "WCB Employer Number" has been assigned, all outgoing WCB notices will carry this number. Future filings should indicate this number when it is known. This field allows for 10 numeric characters. Please refer to the Mandatory Requirements explanation below.
9. EMPLOYER FEIN
Enter the nine digit Federal Employer's Identification Number. If the transaction pertains to a subsidiary, the FEIN of the subsidiary MUST be used. This field allows for 9 numeric characters. Please refer to the Mandatory Requirements explanation below.
The EMPLOYER FEIN is MANDATORY for all transactions with the exception of cancellations. Cancellation transactions MUST contain at least one of these numbers (WCB EMPLOYER NUMBER, NYS UIER NUMBER, EMPLOYER FEIN) for the Board to accept the filing.
10. EMPLOYER'S LEGAL NAME, INCLUDING (DBA/AKA/TA)
This is the employer's legal name as filed under that employer's legal status. A (DBA/AKA/TA) can be included with the employer's legal name but no filings should be made under the (DBA/AKA/TA) name by itself. DO NOT file for Divisions or locations of the employer. The name area is comprised of 4 fields:
Name: this is mandatory and allows for 120 alpha/numeric characters for the legal name
d/b/a: allows for 60 alpha/numeric characters for any DBA/AKA/TA name
c/o: allows for 60 alpha numeric characters for any "care of" name
Attn: allows for 45 alpha/numeric characters for any "Attn" name
This is the main or corporate office street address of the employer where those responsible for obtaining DB insurance coverage are located. This field can contain two rows of data each no longer than 30 alpha/numeric characters.
12. CITY STATE & ZIP CODE
The CITY is MANDATORY and this field allows for 20 alpha/numeric characters. The STATE, US TERRITORY, or CANADIAN PROVINCE is MANDATORY. This field allows for 2 alpha/numeric characters. The ZIP or POSTAL CODE is MANDATORY for all US, US territories, Canadian provinces, and UK addresses. This field allows for 9 alpha/numeric characters.
13. LEGAL STATUS
This field is MANDATORY. Choose the appropriate entry from the drop down list.
14. # OF EMPLOYEES
This is the number of employees covered under the policy that are eligible for DB. This field is MANDATORY and it allows for 6 numeric characters.
15. TELEPHONE NUMBER
This field provides for 10 numeric characters.
* If the policyholder is an Association, Union, or Trustee for which Form DB 820.3 is filed, do not complete items 16 and 18.
16. POLICY NUMBER*
This is the policy number issued by the carrier/insurer. This field is MANDATORY when the DB 820.3 is not required. This field provides for 20 alpha/numeric characters.
17. POLICY EFFECTIVE DATE
This is the effective date the policy covers the legal entity indicated on the filing document. If a new legal entity is being added to an existing policy, indicate the effective date the added entity is covered by the policy NOT the original effective date of the policy. This policy effective date should also be used for any future filings made for this entity. This field allows for 8 numeric characters.
18. POLICY FORM NUMBER*
This is the policy form number issued by the carrier/insurer. This field allows for 18 alpha/numeric characters.
19. WCB PLAN NUMBER (ONLY FOR ASSOCIATION, UNION OR TRUSTEE WITH FORM DB 801 ON FILE)
This is the four-digit WCB assigned plan number. This field is MANDATORY for associations, unions or trustees with form DB 801 on file.
20. PREMIUM AMOUNT
The annual premium amount is preferred. Please indicate the premium amount and the period covered. Whole dollar amounts must be shown.
NON- PAYMENT OF PREMIUM
NOT SUBJECT/NO ELIGIBLE EMPLOYEES
If selected, indicate the date when the employer was not subject or had no eligible employees.
OUT OF BUSINESS
If selected, indicate the date the employer went out of business.
If selected, indicate the date the employer had no employees due to seasonal business.
The date that notice of cancellation or termination was sent to the employer MUST be provided for any reason. This field allows for 8 alpha/numeric characters.
The effective date of cancellation is to be entered in the Transaction Effective Date response box at the top of the DB 820/829 form.
ONLY complete items for FORMER name, address, or policy information that is being changed. Please note both policy number and effective date for any change to the policy.
The effective date of the superseding change is to be entered in the Transaction Effective Date at the top of the DB 820/829 form.
ONLY complete this section if the policyholder is different than the employer being covered by the policy. When the policyholder is different than the employer, name, and address data is MANDATORY.
SECTIONS A, B AND C MUST ALWAYS BE COMPLETED.
INITIAL FILING OF CERTIFICATE OF INSURANCE: Sections A, B and C MUST be completed.
CANCELLATIONS: Sections A, B, C and D MUST be completed. Select the reason for cancellation and provide effective date if required. All cancellations must be filed strictly in accordance with Section 226,subdivision 5 of the Disability Benefits Law.
REINSTATEMENTS: Sections A, B and C MUST be completed.
SUPERSEDES: Sections A, B, C and E MUST be completed. Provide the new information in Section B or C and give the previously reported information for what is being changed in the appropriate field(s) in Section E. Please note both policy number and effective date for any change to the policy.
NOTE: If there has been a legal entity change, do not file as supersedes. To process the legal entity change, you must file a cancellation for the old legal entity and also file a separate initial filing transaction with a current coverage effective date for the new legal entity.
NOTE: Policies that cover only a specific class or classes of employees, policies that cover participating employers in a Board approved Association, Union or Trust, and policies that have attached form DB820.1 must be filed in hard copy (DB-820/829) and forwarded to the Plans Acceptance Unit.