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Workers' Compensation Board

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Disability Benefits Forms for 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 your local WCB District Office.


Popular Forms

 

Form Number /
Version Date
Form Title Who Files Where to File When to File
C-DB-22 Employer's Statement (for Form DB-450) (NY State Insurance Fund) This is a New York State Insurance Fund Link to External Website form.

The State Insurance Fund has pre-printed Form DB-450 with the Employer's Statement on the reverse.
   
CE-200 (12/08) Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage Applicants for permits, licenses or contracts from State, county or municipal agencies in New York State that are not required to carry NYS workers' compensation and/or disability benefits insurance coverage. Please file with the government agency that is issuing the permit, license or contract. (Examples: The New York City Department of Buildings or the New York State Department of Health) These exemption forms can ONLY be used to attest to a government entity that an applicant requesting a permit, license or contract from that government entity is not required to carry NYS workers' compensation and/or disability benefits insurance. (Instructions)
DB-102 (obsolete) Information for Employer Regarding Disability Benefits Law General DBL information made available to the public. Not filed Not filed
DB-118 (10/17) Employer's Statement for the Purpose of Terminating Status as a Covered Employer Employer Mail to Workers' Compensation Board, Bureau of Compliance, PO Box 5200, Binghamton, NY 13902-5200 When terminating status as a covered employer.
DB-120 (11/17) Notice of Compliance – New York State Disability Benefits 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 (10/17) Certificate of Insurance Coverage under the NYS Disability and Paid Family Leave Benefits Law Employers 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 (10/17) Certificate of Participation in Disability or Disability and Paid Family Leave Benefits Group Self-Insurance Employers 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-125 (10/17) Employer Identification Information, Disability Benefits Law Employer Given to employees to provide information to facilitate filing of DB claims. Issued to employees upon separation from employment.
DB-135 (10/17) Employer’s Application for Voluntary Coverage (No Employee Contribution) Employer Workers' Compensation Board, Plans Acceptance Unit, 328 State Street, Schenectady, NY 12305 or email to PAU@wcb.ny.gov To voluntarily cover employees for whom DB is not required under the Law with no employee contributions to the cost of the coverage.
DB-136 (8/03) Employer's Application for Voluntary Coverage for Class of Employees For Whom Disability Benefits Are Not Required by Law (Employee Contribution) Employer Workers' Compensation Board, Plans Acceptance Unit, 328 State Street, Schenectady, NY 12305 or PAU@wcb.ny.gov To voluntarily cover employees for whom DB is not required under the Law with employee contributions to the cost of the coverage.
DB-212.3 (10/17) Notice of Election of a Corporation which is required to have Disability and Paid Family Leave Benefits Coverage for its Employees under the Disability and Paid Family Leave Law to Exclude the Sole Shareholder-Officer or One of Two Shareholder-Officers or Shareholder-Officers of the Corporation from Such Coverage Sole Shareholder Officer(s) of a Corporation File with insurance carrier. Board-approved self-insured employers file with WCB Self-Insurance Office. Board-approved group self-insured's file with the WCB Self-Insurance Office and also with your group administrator. Officers are deemed included in insurance contract until election to exclude is filed.
DB-212.5 (10/17) Notice of Election to Voluntarily Exclude Spouse from Coverage Pursuant to Section 212, Subdivision 5 of the NYS Disability and Paid Family Leave Benefits Law Employer File with Insurance carrier or, if Board-approved self-insurer (or no carrier and spouse is only employee), with the WCB. File when election is made to exclude spouse from coverage.
DB-271S (11/17) 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-271SS (11/17) Declaración de derechos (Ley de Beneficios por Discapacidad [Disability Benefits Law, DBL]) Compañía aseguradora/Autoasegurador aprobado por la junta Emitido por el empleador para el empleado discapacitado. Cuando el empleado con cobertura no asista al trabajo por más de 7 días consecutivos por una discapacidad, se deberá llenar un formulario dentro de los siguientes 5 días hábiles o 5 días después de que el empleador sepa o deba saber de su ausencia por discapacidad. Puede elegir la opción que mejor le convenga.
DB-271SC (11/17) 权利声明 (DBL) 保险公司/委员会认可的自我保险者 由雇主签发给残疾员工 如果受承保员工因残疾缺勤超过连续 7 天,则必须在此后的 5 个工作日内签发表单;或者在雇主知晓或应知晓缺勤是由于残疾造成之后的 5 日内签发,以时间较长者为准。
DB-271SH (11/17) Deklarasyon Dwa (Statement of Rights, DBL) Konpayi Asirans/Oto-asirans komisyon an apwouve Patwon an bay anplwaye ki gen andikap yo. Lè yon anplwaye ki kouvri pa vin travay paske li gen yon andikap pou plis pase 7 jou youn dèyè lòt, yo dwe bay fòm lan nan yon delè 5 jou ouvrab apresa; oswa nan yon delè 5 jou apre patwon an konnen oswa dwe konnen absans sa a se paske anplwaye a gen yon andikap, sa ki plis la.
DB-271SI (11/17) Dichiarazione dei diritti (DBL, Legge sui sussidi di invalidità) Compagnia assicurativa/Autoassicurazione approvata dal Comitato Emesso dal datore di lavoro a un dipendente affetto da disabilità Quando un dipendente coperto da assicurazione è assente dal lavoro per oltre 7 giorni consecutivi a causa di una disabilità, il modulo deve essere emesso entro i 5 giorni lavorativi successivi, oppure entro i 5 giorni successivi al giorno in cui il datore di lavoro è o dovrebbe essere a conoscenza che l’assenza è dovuta a disabilità, a seconda di quale dei due periodi risulti maggiore.
DB-271SK (11/17) 권리 진술서 (DBL) 보험사/위원회 인증 자가보험자 고용주가 장애 직원에게 발급 보장 대상의 직원이 장애로 인해 연속 7일 이상 결근할 경우, 그 후 영업일 기준 5일 이내 또는 그러한 결근이 장애로 인한 것임을 고용주가 알게 된 후 5일 이내 중 더 긴 기간을 기준으로 양식을 발급해야 합니다.
DB-271SP (11/17) Oświadczenie o prawach (DBL) Ubezpieczyciel /zatwierdzony przez zarząd samo-ubezpieczyciel Wydawane przez pracodawcę pracownikowi z niepełnosprawnością. Jeżeli pracownik objęty ubezpieczeniem jest nieobecny w pracy z powodu niepełnosprawności przez okres dłuższy niż 7 kolejnych dni, formularz musi być wystawiony w ciągu 5 dni roboczych po tym terminie; lub w ciągu 5 dni po pozyskaniu przez pracodawcę wiedzy lub w czasie, w którym pracodawca powinien wiedzieć, że nieobecność pracownika jest spowodowana niepełnosprawnością, w zależności od tego, która z tych wartości jest większa.
DB-271SR (11/17) Ваши права (согласно закону DBL) Страховая компания или одобренный Комиссией самозастрахованный работодатель Выдается работодателем нетрудоспособному работнику. Когда застрахованный работник отсутствует на работе по причине нетрудоспособности более 7 дней подряд, форма должна быть выдана в течение 5 рабочих дней после этого; или форма должна быть выдана в течение 5 дней с момента, когда работодатель узнал (или должен узнать), что отсутствие вызвано нетрудоспособностью, в зависимости от того, какая дата наступает позже.
DB-791 (2/00) Tables of Permanent Contributions Reference table of employee contributions for employer use Not filed Not filed
DB-801 (10/17) Plan of an Association of Employers or Employees, Union or Trustees Providing Disability and/ or Paid Family Leave Benefits (Application and Agreement) Plan Administrator for Association of Employers or Employees, Union of Trustees files. E-mail to PAU@wcb.ny.gov or mail to Workers’ Compensation Board, Plans Acceptance Unit, P.O. Box 5200, Binghamton, NY 13902-5200 When an Association of Employers or Employees, Union or Trustees wants to become a Plan that provides Disability and/or Paid Family Leave Benefits.
DB-802 (10/17) Application to have Association, Union or Trustees Plan Accepted/Terminated as Employer's Plan Employer files form after Association, Union or Trustee has signed it. E-mail to PAU@wcb.ny.gov or mail to Workers' Compensation Board, Plans Acceptance Unit, P. O. Box 5200, Binghamton, NY 13902-5200 When an employer becomes a participant in a plan administered by an association, union or trust.
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 (3/18) Supplement to Certificate of Insurance Carriers insuring employers for disability and paid family leave benefits through Plan Coverage, Enriched Coverage, or Class Coverage File with Form DB-820-829. Attach to and make part of Form DB-820-829.

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.