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Workers' Compensation Board

Disability Benefits Forms for Employees

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 your local WCB District Office.

Form Number /
Version Date
Form Title Who Files Where to File When to File
DB-130 (1/18) 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 (9/17) 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-450S (9/17) Aviso y constancia de reclamo de beneficios por discapacidad Reclamante Si usted se enferma o queda discapacitado mientras está empleado, o si se enferma o queda discapacitado dentro de las cuatro (4) semanas posteriores al cese de su relación laboral, presente el formulario ante su empleador o su compañía de seguros.

Si se enferma o queda incapacitado después de haber estado desempleado por más de cuatro (4) semanas, presente el formulario con:

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
Preséntelo dentro de los 30 días posteriores a haber contraído la enfermedad o haber quedado discapacitado.
DB-450C (9/17) 关于残障福利申请的通知和证明 申请人 如果您在就业期间或终止雇佣关系后的四 (4) 周内生病或致残,可向您的雇主或其保险公司提出申请。

如果您在失业超过四(4)周后受伤或生病,您可以申请:

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
生病或致残后的 30 天内提出申请。
DB-450H (9/17) Avi ak Prèv Reklamasyon pou Benefis Andikape Moun kap fè reklamasyon Si ou te vin malad oswa andikape pandan ou t ap travay oubyen ou te vin malad oswa andikape nan kat (4) semèn apre ou sispann travay, prezante reklamasyon ou an devan anplwayè ou oswa konpayi asirans li.

Si ou te malad oswa enfim apre ou te pap travay pou plis pase kat semèn, pote ka ou a:

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
Ranpli 30 jou maksimòm aprè ou te vin malad oswa andikape.
DB-450I (9/17) Comunicazione e richiesta di indennità di invalidità Richiedente In caso di malattia o disabilità durante il periodo di impiego oppure in caso di malattia o disabilità entro quattro (4) settimane dalla cessazione dell’impiego, presentare il modulo al proprio datore di lavoro o alla sua compagnia assicurativa.

In caso di malattia o invalidità una volta trascorse più di quattro (4) settimane dalla cessazione del rapporto di lavoro, inviare il modulo a:

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
Presentare entro e non oltre 30 giorni dal momento in cui ci si è ammalati o si è colpiti da disabilità.
DB-450K (9/17) 장애 혜택 청구에 대한 통지 및 증빙 청구인 고용된 상태 또는 고용 종료 후 4주 이내 아프거나 장애가 생긴 경우에는 고용주 또는 고용주의 보험사에 해당 서류를 제출하십시오.

4 주 이상 실직 상태에서 아프거나 장애가있는 경우 다음 주소로 서류를 제출하십시오.

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
아프거나 장애가 생긴 이후 30일 이내에 제출해야 합니다.
DB-450P (9/17) Zawiadomienie i dowód roszczenia o zasiłki z tytułu niezdolności do pracy Wnioskodawca W przypadku choroby lub niepełnosprawności podczas zatrudnienia lub w ciągu czterech (4) tygodni po zakończeniu zatrudnienia należy złożyć u pracodawcy lub jego firmy ubezpieczeniowej.

Jeśli zachorowałeś lub zostałeś niepełnosprawny po ponad czterech (4) tygodniach bezrobocia, zgłoś się do:

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
Należy złożyć nie później niż 30 dni po zachorowaniu lub powstaniu niezdolności do pracy.
DB-450R (9/17) Уведомление и подтверждение о подаче заявления о выплате пособия по нетрудоспособности Заявитель Если вы заболели или потеряли трудоспособность в период занятости либо заболели или потеряли трудоспособность в течение 4 (четырех) недель после прекращения занятости, подайте заявление по месту работы или в страховую компанию работодателя.

Если вы заболели или потеряли трудоспособность в период отсутствия работы в течение более чем 4 (четырех) недель, подайте заявление в:

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
Подавайте заявление не позднее 30 дней после того, как вы заболели или потеряли трудоспособность.
DB-450B (9/17) ডিজেবিলিটি বেনিফিট দাবির নোটিশ এবং প্রমাণ দাবিদার চাকরির সময় অসুস্থ বা অক্ষম হয়ে গেলে অথবা চাকরি শেষ হওয়ার চার (4) সপ্তাহের মধ্যে অসুস্থ বা অক্ষম হয়ে গেলে আপনার নিয়োগকর্তার নিকটে বা তার বীমা ক্যারিয়ারের নিকট দায়ের করুন।

আপনি চার (4) সপ্তাহ বা তার বেশি সময় ধরে বেকার হয়ে যাওয়ার পরে অসুস্থ বা অক্ষম হয়ে গেলে, এর নিকটে দায়ের করুন:

Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
অসুস্থ বা অক্ষম হওয়ার 30 দিনের বেশি সময় পরে দায়ের করবেন না।
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.
DB-450.1S (9-17) Declaración del reclamante con respecto a una lesión personal o por motivos ajenos a él Reclamante Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
Presentar junto con el Formulario DB-450.
DB-450.1C (9-17) 申请人关于无过失或人身伤害的声明 申请人 Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
随表格 DB-450 一并提交。
DB-450.1H (9-17) Deklarasyon moun kap fè reklamasyon an Konsènan Absans fòt oswa Chòk aksidan Moun kap fè reklamasyon Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
Ranpli Fòm nan ak Fòm DB-450.
DB-450.1I (9-17) Dichiarazione del richiedente riguardo all’assenza di colpa o lesioni personali Richiedente Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
Presentare unitamente al modulo DB-450.
DB-450.1K (9-17) 무과실 또는 개인 상해에 관한 청구인 진술서 청구인 Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
양식 DB-450과 함께 제출하십시오.
DB-450.1P (9-17) Oświadczenie wnioskodawcy dotyczące braku szkód lub obrażeń osobistych Wnioskodawca Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
Złożyć z formularzem DB-450.
DB-450.1R (9-17) Заявление о несчастном случае или травме Заявитель Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
Подавать вместе с документом DB-450.
DB-450.1B (9/17) কোন ত্রুটি বা ব্যক্তিগত কারণে আঘাতপ্রাপ্ত নন, এই সম্পর্কে দাবিদারের বিবৃতি দাবিদার Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
DB-450 ফরম ব্যবহার করে ফাইল করুন

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