New York > Workers Compensation
Employer Identification Card DB-125 - New York
| Employer Identification Card Form. This is a New York form and can be used in Workers Compensation . |
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DISABILITY BENEFITS LAW STATE OF NEW YORK EMPLOYER IDENTIFICATION CARD For use by employee when filing a claim for Disability Benefits for off-the-job injury or sickness. DISABILITY BENEFITS HAVE BEEN PROVIDED BY: Name__________________________________ Address_________________________________ _______________________________________ EMPLOYER U.I. NUMBER BY INSURING WITH:__________________________ ____________________________________________ ____________________________________________ DB-125 (2-05) KEEP THIS CARD The information on this card is important if you file a claim for Disability Benefits while you are unemployed. If you become sick or disabled DURING the first four (4) weeks of unemployment, NOTIFY your LAST employer or its carrier using Form DB-450. If you become sick or disabled AFTER the first four (4) weeks of unemployment, file your claim with the Workers Compensation Board on Form DB-300. For additional information on Disability Benefits call or write the WORKERS COMPENSATION BOARD Office at: 100 Broadway Menands ALBANY 12241-0005 (800) 353-3092 DB-125 (2-05) Reverse www.wcb.state.ny.us American LegalNet, Inc. www.USCourtForms.com
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