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Glossary of WCB Terms

Disability Benefits Forms for
Insurance Carriers and Self-Insured Employers

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader Link to External Website which is available as a free download from Adobe's web site.

After the form opens in your browser, you may complete the form by typing information on the form before you print it.

IMPORTANT: Two-sided and multi-page forms are to be printed and submitted to the Board in duplex format. If this is not possible, submit as separate sheets. However, do NOT submit to the Board any sheets that contain only instructions and/or reference material. Parties of interest other than the Board must receive both sides of all two-sided forms and all pages of multi-page forms.

If you require assistance with completing these forms, please contact the Self Insurance Office at 518-402-0247.

Please note: Forms C-105, C-105.1, C-105.2, DB-120 and DB-120.1 are not available on this site. Contact your insurance carrier or licensed NYS insurance agent for these forms. Carriers and their licensed agents may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website.


Popular Forms

 

Forms for Self-Insured Employers
Form Number /
Version Date
Form Title Who Files Where to File When to File
DB-120 (6/10) Notice of Compliance - Disability Benefits Law Employers insured for disability benefits through an insurance carrier or Board-approved self-insurance. This form is not filed. It must be completed with identifying insurance information and displayed in the workplace. Upon securing of disability benefits insurance or Board-approved self-insurance. Employers must obtain this form from their insurance carrier or licensed agent.

Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website.
DB-120.1 (12/13) Certificate Of Insurance Coverage Under The NYS Disability Benefits Law Employers insured for NYS statutory disability benefits insurance through an insurance carrier. Filed with any entity requesting to be a certificate holder including a government agency issuing a permit, license or contract. The DB-120.1 must be completed by either the NYS statutory disability benefits insurance carrier, or a licensed NYS insurance agent of that carrier. Employers must obtain this form from either their NYS statutory disability benefits insurance carrier or a licensed NYS insurance agent of that carrier.

Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on this website.
DB-120.2 (2/13) Certificate of Participation in Disability Benefits Group Self-Insurance Employers participating in disability benefits group self-insurance plans for workers' compensation Filed with any entity requesting to be a certificate holder including a government agency issuing a permit, license or contract. The DB-120.2 must be completed by the Plan Administrator or Authorized Representative. Employers must obtain this form from their administrator. The administrator should contact Certificates@wcb.ny.gov to get a copy of the form they can distribute to their members.
DB-120.10 (1/09) Gummed Label for Use with Form DB-120 Upon Renewal of Policy Not Filed Upon renewal of a policy, employers receive this gummed label from their disability benefits insurance carrier. Employers then place the DB-120.10 label over the expired policy information on the bottom of Form DB-120. Upon renewal of a disability benefits insurance policy, a carrier may issue this label with updated policy information in lieu of issuing an entire new Form DB-120 poster, as long as the current version of Form DB-120 is already being used. Employers must obtain this form from their insurance carrier. Carriers may contact the Board's Forms Department.
DB-150 (01/04) Application for Self-Insurance for Disability Benefits Employer Filed when applying for self-insurance under the DBL No filing deadline
DB-155 (7/09) Compliance With Disability Benefits Law Employers with Board-approved self-insurance for disability benefits Filed with the government agency issuing a permit, license or contract. The DB-155 must be completed by the Board's Self-Insurance Office. Upon obtaining a permit, license or contract from a government agency. Board-approved self-insured employers must obtain this form from Board's Self-Insurance Office. (518-402-0247)
DB-159.1 (2/03) Notice of Termination of Employer's Participation in Self-Insured Association, Union or Trustees Plan Self-Insured Association, Union or Trustees Plan Administrator One copy to: Workers' Compensation Board, Disability Benefits Bureau, Plans Acceptance Unit, 100 Broadway, Albany, NY 12241; one copy is sent to the employer When participation in a Board-approved self-insured association, union or trustees plan is terminated.
DB-271S (1/11) Statement of Rights (DBL) Insurance Carrier/Board-approved self-insurer Issued by employer to disabled employee. When covered employee is absent from work due to disability for more than 7 consecutive days, form must be issued within 5 business days thereafter; or within 5 days after employer knows or should know that absence is due to disability, whichever is greater.
DB-451 (3/99) Notice of Total or Partial Rejection of Claim for Disability Benefits Insurance Carrier/Board-approved self-insurer Sent to claimant, in triplicate. Within 45 days of receipt of claim.
Carriers and Board-approved Self-Insurers may contact the Board's Forms Department to obtain this form.
DB-455 (3/99) Notice of Disability Benefits Payment Insurance Carrier/Board-approved self-insurer Filed with WCB Disability Benefits Bureau, Albany Upon making initial payment of disability benefits.
DB-470 (11/09) Preliminary/Final Claim for Reimbursement of Benefits Paid Under DBL Disability Benefits Insurance Carrier Workers' Compensation Board, copies to workers' compensation carrier, claimant and his/her representative. Prior to award of workers' compensation benefits.
Carriers and Board-approved Self-Insurers may contact the Board's Forms Department to obtain this form.
DB-820/829 (5/07) Certificate/Cancellation of Insurance Carriers insuring employers for disability benefits through Plan Coverage, Enriched Coverage, or Class Coverage. ONLY insurers providing Plan Coverage, Enriched Coverage, or Class Coverage file this paper form with the Disability Benefits Office at the Workers' Compensation Board to show proof of statutory disability benefits coverage. Upon writing a disability benefits policy for Plan Coverage, Enriched Coverage, or Class Coverage.
DB-820.1 (10/08) Supplement to Certificate of Insurance DB Insurance Carrier NYS Workers' Compensation Board, Disability Benefits Bureau, 100 Broadway, Albany, NY 12241 Attached to Form DB-820/829 when an employer is providing Disability Benefits that are greater than those provided under the Statute.
DB-840 (2/00) Carrier's Designation of Authorized Representatives Insurance Carrier Disability Benefits Bureau Whenever authorized representatives change or when directed by WCB.
DB-850 (3/02) Application for Acceptance of Insurance Form Insurance Carrier Disability Benefits Bureau, Insurance Examining Unit Whenever a new contract form is submitted for acceptance.
OC-110AORD (7-10) Request for Judicial Order – Access to Case Files Individuals or Entities not considered parties in interest who are seeking access to case files Workers' Compensation Board As needed. This form may be submitted in person at any Board office, mailed or faxed (877-533-0337) to the Board.

 

Self-Insurance Annual Report Forms and Guides
Form Number / Version Date Form Title Who Files When Due Where to Submit Description of Form
Annual Reporting Memo Annual Reporting Memo to Self-Insurers Providing Benefits Under the Disability Benefits Law Not Filed-Information for Self-Insured Employer submitting annual reports N/A N/A Reminder announcement of Self-Insurers' requirement to submit annual reports
DB-681 (11/12) Self-Insurer's Annual Report for Calendar Year Qualified Active Self-Insurer January 31 WCB-see Annual Reporting Memo for address Report of Employees, Payroll & Claims
DB-681.1 (11/12) Self-Insurer's Report for Calendar Year of Excess Employee Contributions and Disposition for Calendar year Qualified Active Self-Insurer January 31 WCB-see Annual Reporting Memo for address Report of Employee Contributions
DB-691 (11/12) Instructions for Completion of DB-681 & DB-681.1 Not Filed-Information for Self-Insured Employer submitting annual reports NA NA Instructions for completion of DB Annual Reports
DB Annual Records Update Self-Insurer's Annual Update Form Qualified Active Self-Insurer January 31 WCB-see Annual Reporting Memo for address Self-Insurer's company, contact, address, and TPA information update

 

If the form you are looking for is not listed above, or in the list of Common Board Forms, please e-mail the Board's Forms Department.