New York > Workers Compensation
Notice And Proof Of Claim For Disability Benefits By Unemployed Claimant DB-300 - New York
| Notice And Proof Of Claim For Disability Benefits By Unemployed Claimant Form. This is a New York form and can be used in Workers Compensation . |
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. STATE OF NEW YORK WORKERS' COMPENSATION :BOARD Index No. Calendar No. NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS BY UNEMPLOYED CLAIMANT : JUDICIAL SUBPOENA IMPORTANT: USE THIS FORM ONLY WHEN YOU BECOME SICK OR DISABLED AFTER FOUR (4) WEEKS OF UNEMPLOYMENT. OTHERWISE Plaintiff(s) USE CLAIM FORM DB-450. BEFORE COMPLETING THIS STATEMENT READ INSTRUCTIONS ON REVERSE SIDE. DISABILITY BENEFITS BUREAU 100 BROADWAY-MENANDS ALBANY, NY. 12241 - 0005 : PART A-CLAIMANT'S STATEMENT (Please Print or Type) (Please Print) First Middle -against- : : Last : a. My Social Security Number is: 1. My name is................................................................................................................................................. 2. a. Address.......................................................................................................................................................................................................... Number Street City or Town State Zip Code Apt. No. b. Tel. No..................................................... 3. Sex ........................ 4. Date of Birth........................................ 5. Married Yes No Defendant(s) : 6. My disability is.(if .injury, also . . . . . . . . when . . . . . . . . it . . . . . . . .............................................................................................................. . . . . . . . . . . . . . . . state how, . . . . and where . occurred) . . . . . . . . ............................................................................................................................................................................................................................ 7. The first day I was not "able to work" or became ineligible for Unemployment Insurance because of this disability was: THE PEOPLE OF THE STATE OF NEW YORK Month..................................Day.................................Year................ 8. Have you recovered from this disability? If "Yes", what was the date you were able to work: Yes No TO Month.......................................Day....................................Year..................... Yes No If "Yes",................................................... Name of Union and Local Number 9. My job is or was........................................................ 10. Union Member? Occupation 11. Give name of last employer. If more than one employer during last (8) weeks, name all employers. GREETINGS: Firm or Trade Name WE a. LAST EMPLOYER PERIOD OF EMPLOYMENT Address First Day COMMAND YOU, that all businessTelephone No. being laid aside,Last day worked of you attend before and excuses you and each , the Honorable at the Court Mo. Day Yr. Mo. Day Yr. located at County of b. OTHER EMPLOYERS (during last eight (8) weeks) PERIODS in or Trade , on the dayAddress of , 20 , at Telephoneo'clock in the First Day OFand atLast Day noon, EMPLOYMENT any recessed Firm room Name No. or adjourned date, to testify and give evidence as a witness in this action on the part of the Average Weekly Wage (Include Bonuses, Tips Commissions, Reasonable Value of Board, rent, etc.) 12. Were you claiming or receiving unemployment prior to this disability? Yes No a. If Yes, give Your failure toNo...........................Location.............................................Date youof court and will make you liable U.I. Local Office comply with this subpoena is punishable as a contempt last reported.............................. reasons fully..................................................................................................................................................................................... to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a b. resultdid not claim or if you claimed but did not receive unemployment insurance benefits after LAST DAY WORKED, explain If you of your failure to comply. ......................................................................................................................................................................................................... Witness, Honorable , one of the Justices of the Court in County, day of , 20 ......................................................................................................................................................................................................... 13. For the period of disability covered by this claim are you: a. receiving wages or salary? Yes No b. receiving,or claiming: (Attorney must sign above and type name below) (1) Workers' Compensation for Work-connected Disability Yes No (2) Damages for other Personal Injury Yes No (3) Disability Benefits under the Federal Social Security Act Yes No 14. In the year (52 weeks) before your disability began, have you received disability benefits for other periods of disability? Attorney(s) for Yes No If yes, fill in the following: Paid by...................................................From....................................To................................... I hereby claim Disability Benefits and certify that my disability began while I was unemployed; that I had been unemployed for more than four (4) weeks before I became disabled; and that the foregoing statements, including any accompanying statements are, to the best of my knowledge, true and complete. Office and P.O. Address SIGN Claimant's Signature............................................................................................... Date claim signed.......................................................... HERE If signed by other than claimant, print below: name, address, and relationship of representative. Name and address..........................................................................................................................Relationship............................................ Telephone No.: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF E-Mail CONTAINING THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION Address: ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. Facsimile No.: Mobile Tel. No.: DB-300 (2-04) HEALTH
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