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. |
| 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. |
| DB-450 (2/04) | Aviso y prueba de reclamo por beneficios de discapacidad | Empleado | Presentar ante el empleador o su compañía de seguros si usted se convierte en discapacitado mientras estaba como empleado o dentro de un período de 4 semanas posteriores a la rescisión. |
Presente antes de los 30 días después de enfermarse o encontrarse como discapacitado.
Tenga en cuenta: Hay un espacio en blanco en el reverso de este formulario para la Declaración del empleador (Parte C). No es requerido por la Junta de compensación para los trabajadores, pero puede agregarse a discreción de la compañía aseguradora. |
| DB-450 (2/04) | Notice and Proof of Claim for Disability Benefits | 員工 | 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. |
| DB-450 (2/04) | Avi ak Prèv Reklamasyon pou Avantaj akòz Andikap | >Anplwaye | Ranpli fòm nan avèk patwon an oswa avèk konpayi asirans li si ou vin andikape pandan w ap travay oswa nan 4 semèn apre revokasyon ou. | Fè reklamasyon an nan egzakteman 30 jou apre ou vin malad oswa andikape. Tanpri sonje: Gen espas vid ki disponib sou lòt bò fèm sa a pou yon Deklarasyon Patwon an (Pati C). Li pa obligatwa pou Komisyon Konpansasyon an, men ou ka mete li selon desizyon konpayi asirans lan. |
| DB-450 (2/04) | Comunicazione e Bozza di ricorso | >Dipendente | Presentare al datore di lavoro o alla sua compagnia di assicurazione in caso di sopravvenuta disabilità durante la durata del contratto di lavoro o entro 4 settimane dalla sua conclusione. | Presentare entro 30 giorni dalla sopravvenuta malattia o disabilità. Nota: Sul retro di questo modulo è disponibile uno spazio bianco per una dichiarazione del datore di lavoro (Parte C). Non è richiesta dal Workers Compensation Board, ma può essere aggiunta a discrezione dell'assicuratore. |
| DB-450 (2/04) | 장애 보상 청구 및 증빙 | >직원 | 고용중이거나 고용해지로부터 4주 이내인 경우 고용주 또는 보험사에 제출 | 아프거나 장애를 얻게 된 때로부터 30일 이내 참고 사항: 이 양식 뒷면의 공백에 고용주의 진술서 첨부 가능(Part C). 이는 직원 보상 위원회의 요구 사항은 아니지만 보험사 재량으로 추가될 수 있습니다. |
| DB-450 (2/04) | Zawiadomienie i dowód roszczenia o zasiłki z tytułu niezdolności do pracy | Pracownik | Składane u pracodawcy lub jego firmy ubezpieczeniowej w przypadku niezdolności do pracy podczas zatrudnienia lub w ciągu 4 tygodni po rozwiązaniu stosunku pracy. | Składane nie później niż 30 dni po zachorowaniu lub powstaniu niezdolności do pracy. Uwaga! Puste miejsce na odwrocie tego formularza jest przeznaczone na oświadczenie pracodawcy (część C). Nie jest ono wymagane przez Komisję ds. Odszkodowań Pracowniczych, może być jednak dodane wg uznania. |
| DB-450 (2/04) | Уведомление о заявлении и подтверждение заявления на получение пособий по инвалидности | Работник | Подавать работодателю или в страховую компанию работодателя в случае потери трудоспособно-сти в период трудоустройства или в течение 4 недель после увольнения. | Подавать не позднее чем через 30 дней после возникновения заболевания или получения инвалидности. Обратите внимание! Пустое поле для заявления работодателя имеется на оборотной стороне данного бланка (Часть С). Указанное заявление не требуется Комиссией по компенсационным выплатам работникам, но может быть добавлено по решению страховщика. |
If the form you are looking for is not listed above, or in the list of Common Board Forms, please contact the Board.
