WORKERS' COMPENSATION BOARD STATE OF NEW YORK NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS BY UNEMPLOYED CLAIMANT IMPORTANT: USE THIS FORM ONLY WHEN YOU BECOME SICK OR DISABLED AFTER FOUR (4) WEEKS OF UNEMPLOYMENT. OTHERWISE USE CLAIM FORM DB-450. BEFORE COMPLETING THIS STATEMENT READ INSTRUCTIONS ON REVERSE SIDE. DISABILITY BENEFITS BUREAU 328 STATE STREET SCHENECTADY, NY 12305 PART A-CLAIMANT'S STATEMENT (Please Print or Type) 1. My name is................................................................................................................................................. (Please Print) First Middle Last a. My Social Security Number 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 6. My disability is (if injury, also state how, when and where it occurred) ............................................................................................................. ............................................................................................................................................................................................................................ 7. The first day I was not "able to work" or became ineligible for Unemployment Insurance because of this disability was: Month..................................Day.................................Year................ 8. Have you recovered from this disability? If "Yes", what was the date you were able to work: Occupation Yes No Month.......................................Day....................................Year..................... Yes No If "Yes",................................................... Name of Union and Local Number 9. My job is or was........................................................ 10. Union Member? 11. Give name of last employer. If more than one employer during last (8) weeks, name all employers. a. LAST EMPLOYER Firm or Trade Name Address Telephone No. PERIOD OF EMPLOYMENT First Day Mo. Day Firm or Trade Name b. OTHER EMPLOYERS (during last eight (8) weeks) Address Telephone No. Yr. Last day worked Mo. Day Yr. Average Weekly Wage (Include Bonuses, Tips Commissions, Reasonable Value of Board, rent, etc.) PERIODS OF EMPLOYMENT First Day Last Day 12. Were you claiming or receiving unemployment prior to this disability? Yes No a. If Yes, give U.I. Local Office No...........................Location.............................................Date you last reported.............................. b. If you did not claim or if you claimed but did not receive unemployment insurance benefits after LAST DAY WORKED, explain reasons fully..................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... 13. For the period of disability covered by this claim are you: a. receiving wages or salary? Yes No b. receiving,or claiming: (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? 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. SIGN Claimant's Signature............................................................................................... Date claim signed.......................................................... If signed by other than claimant, print below: name, address, and relationship of representative. HERE Name and address..........................................................................................................................Relationship............................................ 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. DB-300 (2-04) HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERSE SIDE American LegalNet, Inc. www.FormsWorkFlow.com PART B - HEALTH CARE PROVIDER'S STATEMENT (Please Print or Type) THE HEALTH CARE PROVIDER'S STATEMENT MUST BE FILLED IN COMPLETELY. THE ATTENDING HEALTH CARE PROVIDER SHALL COMPLETE AND MAIL SUCH FORM TO THE WORKERS' COMPENSATION BOARD (SEE ADDRESS BELOW), OR RETURN IT TO THE CLAIMANT, WITHIN SEVEN (7) DAYS OF RECEIPT OF THIS FORM. For item 7-d, give approximate date. Make some estimate. If disability is caused by or arising in connection with pregnancy, enter estimated delivery date under "Remarks." INCOMPLETE ANSWERS MAY DELAY PAYMENT OF BENEFITS. First Middle Initial 1. Claimant's Name.....................................................................................................................................2. Date of Birth.................3. Sex................. 4. Diagnosis/Analysis:...................................................................................................................................................................................................... a. Claimant's symptoms:.........................