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Disability Benefits Forms Insurers and Self-Insured Employers

Forms

Completing Forms

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. Please enter your information, select print and choose Microsoft Print to PDF and submit the saved PDF. Please note, that if you do not Print to PDF, the entered data may not be transmitted resulting in a blank form being submitted. 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.

Certificates of Insurance
Forms DB-120, DB-120.1 and DB-155 are not available on this site.

Popular Forms


If you require assistance with completing these forms, please contact the Self-Insurance Office via email at selfinsurance@wcb.ny.gov

Self-Insurance Application Forms
Form Number / Version Date Form Title Who Files Description of Form When to File
DB-26 (10/17) Notice of Election of Political Subdivision for Self-Insurance-Disability and Paid Family Leave Benefits Law Political subdivision, ambulance or fire district Notice to the Chair that a political subdivision, ambulance or fire district has elected to secure Disability and/or Paid Family Leave benefits as a self-insurer When appropriate
DB-150 (1/24) Application for Self-Insurance-Disability and Paid Family Leave Benefits Employer Filed when applying for self-insurance under the Disability and Paid Family Leave Benefits Law No filing deadline
Self-Insurance Annual Report Forms and Guides
Form Number / Version Date Form Title Who Files When Due Where to Submit Description of Form
DB-681 (12/19) Self-Insurer's Annual Report for Calendar Year Qualified Active Self-Insurer January 31 Email completed form to the Workers’ Compensation Board at selfinsurance@wcb.ny.gov Report of Employees, Payroll & Contact Information

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

Forms for Insurance Carriers and Self-Insured Employers
Form Number /
Version Date		 Form Title Who Files Where to File When to File
DB-120 (11/17) Notice of Compliance - Disability Benefits Law Employers insured for disability benefits through an insurance carrier or Board-approved self-insurance. This form is not filed. It is completed by the licensed insurance carrier or self-insured administrator with identifying insurance information and then displayed by the employer 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. It is normally provided in the insurance policy package.
DB-120.1 (12/21) 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.
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-120.10 (1/09) Gummed Label for Use with Form DB-120 Upon Renewal of Policy Not Filed Upon renewal of a policy, employers receive this gummed label from their disability benefits insurance carrier. Employers then place the DB-120.10 label over the expired policy information on the bottom of Form DB-120. Upon renewal of a disability benefits insurance policy, a carrier may issue this label with updated policy information in lieu of issuing an entire new Form DB-120 poster, as long as the current version of Form DB-120 is already being used. Employers must obtain this form from their insurance carrier. Carriers may contact the Board's Forms Department.
DB-155 (9/16) Certificate of Self-Insurance Coverage under the NYS Disability and Paid Family Leave Benefits Law Employers with Board-approved self-insurance for disability benefits Filed with the government agency issuing a permit, license or contract. The DB-155 must be completed by the Board's Self-Insurance Office. Upon obtaining a permit, license or contract from a government agency. Board-approved self-insured employers must obtain this form from the Board's Self-Insurance Office by emailing selfinsurance@wcb.ny.gov
DB-271S (12/23) 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-451 (5/19)

The Board will only accept the current version of this form. 		Notice of Total or Partial Rejection of Claim for Disability Benefits Insurance Carrier/Board-approved self-insurer Send one copy to claimant. Within 45 days of receipt of claim.
Carriers and Board-approved Self-Insurers may contact the Board's Forms Department to obtain this form.
DB-470 (6/22)

The Board will only accept the current version of this form. 		Preliminary/Final Claim for Reimbursement of Benefits Paid Under DBL Disability Benefits Insurance Carrier Workers' Compensation Board, copies to workers' compensation carrier, claimant and claimant's representative. Prior to award of workers' compensation benefits.
Carriers and Board-approved Self-Insurers may contact the Board's Forms Department to obtain this form.
DB-800 (1/24) Self-Insured Employers providing Disability and/or Paid Family Leave Benefits offering a shorter waiting period or a longer duration than statute requires (Application and Agreement) Self-Insured Employers providing Disability and/or Paid Family Leave Benefits offering a shorter waiting period or a longer duration than statute requires Email to PAU@wcb.ny.gov or mail to Workers’ Compensation Board, Plans Acceptance Unit, P.O. Box 5200, Binghamton, NY 13902-5200 When a Self-Insured Employer wants to provide Disability and/or Paid Family Leave Benefits to a Class of employees and/or offers a shorter waiting period, or a longer duration than statue requires.
DB-820/829 (9/17) Certificate/Cancellation of Insurance Carriers insuring employers for disability and paid family leave 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 and paid family leave benefits coverage. Upon writing a disability and paid family leave benefits policy for Plan Coverage, Enriched Coverage, or Class Coverage. Carriers may contact the Board's Forms Department to obtain this form.
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.
DB-820.3 (10/17) Certificate of Insurance on behalf of Association, Union or Trustees of Plan benefits. Carriers insuring employers for Disability and Paid Family Leave benefits through Plan Coverage. Carriers are to submit this form to the Board on behalf of the Association, Union or Trust. The form requires a signature from the insurance carrier and an authorized representative from the Association, Union or Trust. Must be filed with the DB-801 initial application. Upon writing a Disability and Paid Family Leave benefits policy for Plan Coverage. Carriers may contact the Board's Forms Department to obtain this form.
DB-829.3 (10/17) Notice of Cancellation for Association, Union or Trustees of Plan benefits. Carriers insuring employers for Disability and Paid Family Leave benefits through Plan Coverage. Carriers are to submit this form to the Board on behalf of the Association, Union or Trust. The form requires a signature from the insurance carrier and an authorized representative from the Association, Union or Trust. Carriers may contact the Board's Forms Department to obtain this form.
DB-850 (10/17) Application for Acceptance of Insurance Form Under Section 360.1(b)(1) NYCRR Insurance Carrier Email to PAU@wcb.ny.gov or mail to Workers' Compensation Board, Plans Acceptance Unit, P. O. Box 5200, Binghamton, NY 13902-5200 File when new forms needs approval.
DB-DEN (10/23) Notice of Denial of Claim for Disability Benefits Insurance Carrier/Board-approved self-insurer Send one copy to claimant Within 18 days of the first day of disability or receipt of the request for disability benefits unless DB-451 is issued in this timeframe. Carriers and Board-approved Self-Insurers may contact the Board's Forms Department.
OC-110AORD (7/10) Request for Judicial Order – Access to Case Files Individuals or Entities not considered parties in interest who are seeking access to case files Workers' Compensation Board As needed. This form may be submitted in person at any Board office, mailed or faxed ((877) 533-0337) to the Board.
PFL-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 email the Board's Forms Department.

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