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TO BE COMPLETED BY EMPLOYER
DB-450 (1-68), Reverse Side
Employee's Full Name:
S. S. Number:
Employee's Address:
Date
Age:
Employee's Occupation:.
Employed.
Full Time ] Part Time
If Part Time, Give Particulars:
Check one ] owner proprietor
employee partner
Earnings 8 weeks prior to disability:
Date Employee Last Worked:
Weak Ending
Mo. Day
No.Days
Amount
Date Employee's Wages Ceased:
Date Employee Returned To Work:
Wages Continued During Disability?.
Is Reimbursement Requested?
Is Disability Due To Job?_
If So, Is a Compensation Claim Filed?_
Check Days Normally Worked Mon. Tues. | Wed.| Thurs. |Fri.| Sat.| Sun.
Total
$ -
Indicate weekly value of board
lodging and tips $ .
Is employee a member of a union? [] Yes []No. If 'yes', give name and address of union and local
THEN FOLD HERE
number_
Firm Name:
Address:
Date_
_Telephone Number
NYDBL Policy No.
Signed By:
_Title
CNAlinsurance
CONTINENTAL CASUALTY CO. / NATIONAL FIRE INSURANCE CO. / AMERICAN CASUALTY COMPANY
CLAIMANT: READ THESE INSTRUCTIONS CAREFULLY BEFORE YOU COMPLETE YOUR CLAIM FOR DISABILITY
BENEFITS. FILE YOUR CLAIM PROMPTLY.
WRITTEN NOTICE AND PROOF OF DISABILITY SHALL BE FURNISHED NOT LATER THAN TWENTY (20) DAYS AFTER
THE COMMENCEMENT OF THE PERIOD OF DISABILITY.
1. USE THIS FORM ONLY IF YOU BECOME SICK OR DISABLED WHILE EMPLOYED OR WITHIN FOUR (4) WEEKS AFTER
TERMINATION OF EMPLOYMENT.
USE GREEN CLAIM FORM DB-300 IF YOU BECOME SICK OR DISABLED AFTER HAVING BEEN UNEMPLOYED MORE
THAN FOUR (4) WEEKS.
2. YOU MUST COMPLETE ALL ITEMS OF THE "CLAIMANT'S STATEMENT." BE ACCURATE. CHECK ALL DATES.
3. BE SURE TO DATE AND SIGN YOUR CLAIM (SEE ITEM 12).
IF YOU CANNOT SIGN THIS CLAIM FORM, YOUR REPRESENTATIVE MAY SIGN IN YOUR BEHALF. IN THAT EVENT,
THE REPRESENTATIVE'S RELATIONSHIP TO YOU AND HIS ADDRESS SHOULD BE NOTED UNDER HIS SIGNATURE.
4. DO NOT MAIL THIS CLAIM UNLESS YOUR DOCTOR HAS COMPLETED AND SIGNED THE "DOCTOR'S STATEMENT."
5. FOLD, SEAL AND ADDRESS THIS CLAIM TO YOUR LAST EMPLOYER OR HIS INSURANCE COMPANY. NO EN-
VELOPE IS REQUIRED. AFFIX POSTAGE BEFORE MAILING.
6. DISABILITY BENEFITS ARE NOT PAYABLE FOR ANY DISABILITY OCCASIONED BY WILFUL INTENTION TO BRING
ABOUT INJURY OR SICKNESS, OR RESULTING FROM INJURY OR SICKNESS SUSTAINED IN THE COMMISSION OF
AN ILLEGAL ACT; OR CAUSED BY, OR RESULTING FROM PREGNANCY, EXCEPT IF PREGNANCY BENEFITS ARE
PROVIDED UNDER AN ACCEPTED PLAN, OR TO THE EXTENT THAT SUBSEQUENT BENEFITS ARE PROVIDED BY LAW.
7. OTHER THAN AS PROVIDED IN AN ACCEPTED PLAN, DISABILITY BENEFITS ARE NOT PAYABLE FOR ANY PERIOD
DURING WHICH YOU
A. BECOME SICK OR DISABLED PRIOR TO THE TIME YOU ARE ELIGIBLE.
B. ARE OR WOULD BE SUBJECT TO SUSPENSION OR DISQUALIFICATION UNDER THE UNEMPLOYMENT IN-
SURANCE LAW.
C. RECEIVE, OR ARE ELIGIBLE TO RECEIVE, UNEMPLOYMENT INSURANCE BENEFITS OF ANY STATE OR OF
THE UNITED STATES.
D. ARE ENTITLED TO RECEIVE FROM YOUR EMPLOYER, OR FROM A FUND TO WHICH YOUR EMPLOYER HAS
CONTRIBUTED, AN AMOUNT EQUAL TO DISABILITY BENEFITS.
E. RECEIVE, OR ARE ENTITLED TO RECEIVE, BENEFITS UNDER ANY WORKMEN'S COMPENSATION ACT (EXCEPT
WORKMEN'S COMPENSATION BENEFITS FOR A PERMANENT DISABILITY OCCURRING PRIOR TO THE DIS-
ABILITY FOR WHICH BENEFITS ARE NOW CLAIMED), DISABILITY LAW OR SIMILAR LAW, THE FEDERAL
EMPLOYER'S LIABILITY ACT, OR UNDER THE MARITIME DOCTRINE OF MAINTENANCE, WAGES AND CURE.
F. PERFORMED WORK FOR REMUNERATION OR PROFIT.
Address
Name of Employer or His Insurance Company
HERE
POSTAGE
PLACE
POSTMASTER, RETURN POSTAGE GUARANTEED
ALBANY, NEW YORK 12204
1949 NO. BROADWAY
DISABILITY BENEFITS BUREAU
WORKMEN'S COMPENSATION BOARD
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