Disability Benefits Forms for Employees
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 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 (5/02) | Employee's Statement of Exempt Status | Employee | One notarized copy to: NYS Workers' Compensation Board Disability Benefits Bureau 100 Broadway Albany, NY 12241 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 Benefits Law |
| DB-300 (2/04) | Notice of Proof of Claim for Disability Benefits of Unemployed Claimant | Claimant | Filed with WCB, Disability Benefits Bureau, Albany, if sick or disabled after 4 weeks of unemployment (see DB-450) | File no later than 30 days after becoming sick or disabled. |
| DB-450 (2/04) | Notice and Proof of Claim for Disability Benefits | Employee | File with employer or its insurance company if you become disabled while employed or within 4 weeks after termination. | File no later than 30 days after becoming sick or disabled. Please note: Blank space is available on the reverse of this form for an Employer's Statement (Part C). It is not required by the Workers' Compensation Board, but may be added at the carrier's discretion. |
| Spanish Information Sheet for Form DB-450 (3-07) Guía Para Llenar El Formulario DB-450, Notificación Y Constancia De La Solicitud De Los Beneficios Por Incapacidad |
Esta guía pretende ayudarles a las personas que hablan español como primer idioma a llenar el Formulario DB-450, que se usa con mayor frecuencia para solicitar los beneficios por incapacidad del Estado de Nueva York (por lesiones o enfermedades sufridas fuera del trabajo). Contiene una traducción de las instrucciones y preguntas que deberá responder en el formulario. Si puede, llene la Parte A del Formulario DB-450 en inglés y siga las instrucciones que se brindan a continuación para presentar la solicitud. El proveedor de servicios de salud que le brinde asistencia médica deberá llenar la Parte B ubicada al dorso del formulario antes de que usted lo presente. No presente esta guía junto con la solicitud. | |||
If the form you are looking for is not listed above, or in the list of Common Board Forms, please contact the Board.
