Disability Benefits Underwriting Forms


NumberNamePurpose
DB-120Notice of Compliance – Disability Benefits Law
Contact us if you did not receive in your DB policy or renewal package.
To be posted in all business locations to show proof of disability benefits insurance.  A DB-120 is provided in both the DB policy and renewal information packages.
DB-135Employer's Application for Voluntary Coverage (No Employee Contribution)To voluntarily cover employees for whom DB is not required under the Law with no employee contributions to the cost of the coverage.  This form is filed by the employer to the WCB, DB Bureau, Albany.
DB-136Employer's Application for Voluntary Coverage (Employee Contribution)To voluntarily cover employees for whom DB is not required under the Law with employee contributions to the cost of the coverage.  This form is filed by the employer to the WCB, DB Bureau, Albany.
DB-212.3Notice 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 CoverageOfficers are deemed included in insurance contract until election to exclude is filed.  File with insurance carrier.  Board approved self-insured employers file with WCB Self-Insurance Office.
DB-212.5Notice of Election to Voluntarily Exclude Spouse from CoverageTo voluntarily exclude spouse from DB coverage.  Form is filed with carrier or, if Board approved self-insurer (or no carrier and spouse is only employee), with the WCB.
UDB-112Request for Inclusion of Additional InterestTo add an additional entity to a disability benefits policy.  The form must be completed in full, signed by a principal or executive officer of both the existing and new company and returned to NYSIF.
UDB-36 DBApplication for Disability Benefits InsuranceTo apply for disability benefits insurance with NYSIF.  Complete application and mail with deposit check to:  NYSIF – Disability Benefits, 15 Computer Drive West, Albany, NY  12205.
UDB-37Assignment of Interest AgreementTo transfer or assign the interest in a policy to another legal entity.

Disability Benefits Claim Forms (non-job related injury or illness)


Number NamePurpose
DB-300Notice and Proof of Claim for Disability Benefits by Unemployed ClaimantTo be filed with WCB, Disability Benefits Bureau, Albany, if sick or disabled after 4 weeks of unemployment.  File no later than 30 days after becoming sick or disabled.
DB-450Notice and Proof of Claim for Disability Benefits. Please note: Part C (employer’s statement) must be completed by employer to ensure timely handling of claim. To be filed with employer’s insurance company if an employee becomes disabled while employed or within 4 weeks after termination.  File no later than 30 days after becoming sick or disabled.

 

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