Skip to Content

Workers’ Compensation Board

Search menu

Save the Date – COVID-19 and Workers’ Compensation Webinars

Language Access Policy  |  Disclaimer Regarding the Use of "Google Translate"

Disability Benefits Forms Employees

Forms

Completing Forms

If you require assistance with completing these forms, please contact us.

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader which is available as a free download from Adobe's website. After the form opens, you may complete the form by typing information on the form before you print it. If you have trouble opening a form: (1) download/save the form onto your computer, (2) open Adobe Reader, (3) open the saved file. If you still have trouble with the form, please email the Board's Forms Department.

Multi-page Forms
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.



Disability Benefits Forms for Employees
Form Number /
Version Date
Form Title Who Files Where to File When to File
DB-130 (5/19) Employee's Statement of Exempt Status Employee One notarized copy to:

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029

And

One notarized copy to your employer
Any employee receiving or entitled to receive Social Security retirement benefits may submit this form at any time to waive any and all benefits under the Disability and Paid Family Leave Benefits Law
DB-450 (6/22) Notice and Proof of Claim for Disability Benefits Claimant If you became sick or disabled while employed or you became sick or disabled within four (4) weeks after termination of employment, file with your employer or its insurance carrier.

If you became sick or disabled after having been unemployed for more than four (4) weeks, file with:

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
File no later than 30 days after becoming sick or disabled.
DB-450.1 (9-17) Claimant's Statement Regarding No Fault or Personal Injury Claimant Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
File with Form DB-450.

If the form you are looking for is not listed above, or in the list of Common Board Forms, please contact the Board.