Form Number /
Version Date |
Form Title |
Who Files |
Where to File |
|
DB-135 (8/03) |
Employer's Application for Voluntary
Coverage for Class of Employees For
Whom Disability Benefits Are Not
Required by Law (No Employee
Contribution) |
Employer |
WCB, Disability Benefits Bureau,
Albany |
|
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 |
WCB, Disability Benefits Bureau,
Albany |
|
DB-212.3 (1/04) |
Notice of Election of a Corporation
Which is Required to Have Disability
Benefits Coverage for its Employees
to Exclude the Sole Shareholder
Officer or One of the Two or Both
Shareholder Officers of the
Corporation from Such Coverage |
Sole Shareholder Officer(s) of a
Corporation |
File with insurance carrier. Self-insureds
file with WCB Self-Insurance Office.
Group self-insureds file with the
WCB Self-Insurance Office and also
with your group administrator. |
|
DB-212.5 (2/00) |
Notice of Election of Voluntarily
Exclude Spouse from Coverage |
Employer |
File with carrier or, if
self-insured or no carrier and
spouse is only employee, with the
WCB. |
|
DB-450 (8/05) |
Notice and Proof of Claim for
Disability Benefits |
Employee |
File with employer or its insurance
company if you become disabled while
employed or within 4 weeks after
termination. |
|
DB-451 (3/99) |
Notice of Total or Partial Rejection
of Claim for Disability Benefits |
Insurance Carrier/Self-Insurer |
Sent to claimant, in triplicate. |
|
DB-802 (4/04) |
Employer's Application to Have
Association, Union or Trustee Plan
Accepted as Employer's Plan |
Employer files form after
Association, Union or Trustee has
signed it. |
Disability Benefits Bureau, Plans
Acceptance Unit |
|
DB - 820/829 (2/05) |
Certificate/Cancellation of
Insurance |
Employers insured for disability
benefits through an insurance
carrier. |
Filed with the government agency
issuing a permit, license or
contract. The DB-820/829 must be
completed by the insurance carrier. |
|
DB-820.1 (9/03) |
Supplement to Certificate of
Insurance |
DB Insurance Carrier |
NYS Workers' Compensation Board,
Disability Benefits Bureau, 100
Broadway, Albany, NY 12241 |
|
DB-850 (3/02) |
Application for Acceptance of
Insurance Form |
Insurance Carrier |
Disability Benefits Bureau,
Insurance Examining Unit |
|
DB-102 (3/04) |
Information for Employer Regarding
Disability Benefits Law |
General DBL information made
available to the public. |
Not filed |
|
DB-125 (2/05) |
Employer Identification Card |
Employer |
Given to employees to provide
information to facilitate filing of
DB claims. |
