If your disability begins while you are working, or within four weeks of your last day worked, you should file a completed DB450 claim form within 30 days of your disability date.
PART A is the Claimant's Statement and is for you to fully complete and sign.
PART B is the Health Care Provider's Statement. You must have your health care provider fully complete this section which certifies that you are unable to work because of your disability.
PART C is the Employer's Statement. Your employer must fully complete Part C of the claim form providing your wage and employment information.
Once all sections are complete you or your employer can submit the claim to us by:
||Standard Security Life Ins. Co of NY
P.O. Box 25339
Farmington, N.Y. 14425
If your disability occurs more than four weeks after your last day of work, and you are receiving NYS Unemployment Benefits you must file a completed DB-300 (http://www.wcb.ny.gov/content/main/forms/db300.pdf) claim form with the Workers' Compensation Board.
Mail the completed form to:
Workers' Compensation Board
Disability Benefits Bureau
328 State Street
Schenectady, NY 12305