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Notice And Proof Of Claim For Disability Benefits DB-450 - New York

Notice And Proof Of Claim For Disability Benefits Form. This is a New York form and can be used in Workers Compensation .
 Fillable pdf Last Modified 4/15/2004
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COURT CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY 1. 2. 3. 4. 5. 6. DISABLED WITHIN FOUR (4) WEEKS AFTER TERMINATION OF EMPLOYMENT. USE CLAIM FORM DB-300 IF YOU BECOME SICK OR DISABLED AFTER HAVING BEEN UNEMPLOYED MORE THAN FOUR (4) WEEKS. YOU MUST COMPLETE ALL ITEMS OF PART A - THE "CLAIMANT'S STATEMENT". : BE ACCURATE. CHECK ALL DATES. Calendar No. BE SURE TO DATE AND SIGN YOUR CLAIM (SEE ITEM 12). IF YOU CANNOT SIGN THIS CLAIM FORM, YOUR REPRESENTATIVE MAY SIGN IT IN YOUR BEHALF. IN THAT EVENT, THE NAME, ADDRESS AND REPRESENTATIVE'S RELATIONSHIP TO YOU SHOULD BE NOTED : UNDER THE SIGNATURE. DO NOT MAIL THIS CLAIM UNLESS YOUR HEALTH CAREPlaintiff(s) PROVIDER COMPLETES AND SIGNS PART B - THE "HEALTH CARE PROVIDER'S STATEMENT." YOUR COMPLETED CLAIM SHOULD BE MAILED WITHIN THIRTY (30) DAYS AFTER YOU BECOME SICK OR DISABLED TO YOUR LAST -against: EMPLOYER OR YOUR LAST EMPLOYER'S INSURANCE COMPANY. MAKE A COPY OF THIS COMPLETED FORM FOR YOUR RECORDS BEFORE YOU SUBMIT IT. COUNTY . . . . . . . . . . . .OF. . . . . . .NOTICE. AND . . . . . . . . . . . . . . . . . . . . .DISABILITY BENEFITS . . . . . . . . . . PROOF OF CLAIM FOR . . . : USE THIS FORM IF YOU BECOME SICK OR DISABLED WHILE EMPLOYED OR IF YOU Index No. BECOME SICK OR JUDICIAL SUBPOENA PART A - CLAIMANT'S STATEMENT (Please Print or Type) ANSWER: ALL QUESTIONS 1. My name is.................................................................................................... : First Middle Last Social Security Number 2. Address................................................................................................................................................................ Number Street City or Defendant(s) State Town Zip Code Apt. No. . .......................... . .... . ... ........... 3. Tel. .No............................................... .4. . Date .of .Birth ................................ 5. Married (Check one) qYes qNo ........................................................................................................................................................................... : 6. My disability is (if injury, also state how, when and where it occurred) ...................................................................... THE PEOPLE OF THE STATE OF NEW YORK 7. I became disabled on ................................................................................ a. I worked on that day Month Day Year q Yes qNo b. TO I have since worked for wages or profit. q Yes q No If "Yes", give dates ........................................................ 8. Give name of last employer. If more than one employer during the last eight (8) weeks, name all employers. EMPLOYER'S DATES OF EMPLOYMENT TELEPHONE NO. FROM Mo. Day Yr. THROUGH Mo. Day Yr. AVERAGE WEEKLY WAGES (Include Bonuses, Tips, Commissions, Reasonable Value of Board, Rent, etc.) GREETINGS: BUSINESS NAME BUSINESS ADDRESS WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed 9. Myor adjourned date, to testify and give evidence as a witness in this action on the part of the job is or was ..................................................................................................... ......................................... Name of Union and Local Number, if Member Occupation 10. For the period of disability covered by this claim a. Are you receiving wages, salary or separation pay: ........................................................... q Yes q No b. Are you receiving or claiming: (1) Workers' compensation for work-connected disability.................................................. q Yes q No Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to (2) Unemployment Insurance Benefits............................................................................. q Yes q No the party on whose behalf this subpoena was issued for a maximum penalty of $50 and allq Yes sustained as a (3) Damages for personal injury ..................................................................................... damages q No (4) Benefits failure to comply. result of your under the Federal Social Security Act for long-term disability ......................... q Yes q No IF "YES" IS CHECKED IN ANY OF THE ITEMS IN 10a OR 10b, COMPLETE THE FOLLOWING: I have q received q claimed from ......................................... for the periodone of the Justices of the Witness, Honorable , ...................... to......................... Date Date 11. I have received disability benefits for another period or periods of disability within the 52 weeks immediately before Court in County, day of , 20 my present disability began ................................................................................................... q Yes q No If "Yes", fill in the following: I have been paid by ..................................................From ................. To .................... Date Date 12. I have read the instructions above. I hereby claim Disability Benefits and certify that for the period covered by this claim I was disabled; and that the foregoing statements, including any accompanying statements, nameto the best of (Attorney must sign above and type are below) my knowledge true and complete. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. Claim signed on ................................................................................................................................................... Date Claimant's Signature Attorney(s) for If signed by other than claimant, print below: name, address, and relationship of representative. .......................................................................................................................................................................... Disclosure of Information: The Board will not disclose any information about your case to any unauthorized party without your consent. If you choose to have such information disclosed to an unauthorized party, you must file with the B
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