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DB-450
NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
IMPORTANT: USE THIS FORM ONLY WHEN THE CLAIMANT BECOMES SICK OR DISABLED WHILE EMPLOYED OR
WITHIN FOUR (4) WEEKS AFTER TERMINATION OF EMPLOYMENT. OTHERWISE USE GREEN CLAIM FORM DB-300.
DOCTOR'S STATEMENT
Benefits may be prevented.
The doctor's statement must be filled in completely. For item 6-d, give approximate date. Make some estimate. Delay in the payment of Disability
1. Claimant's Name....
Middle
2. Age..
Male
4. Diagnosis:.........."
Female
a. Claimant's Symptoms:.
b. Objective Findings:..
5. Operation Indicated? YES NO .. Type.....
b. Date ...............".
.......
6. Enter Dates for the Following:
Month
Day
Year
a. Date of your first treatment for this disability...
b. Date of your most recent treatment for this disability.......................
c. Date Claimant was unable to work because of this disability.............
d. Date Claimant will be able to perform usual work...
7. In your opinion, is this disability the result of injury arising out of and in the
course of employment or occupational disease? YES NO
Remarks:..
am a physician duly authorized by the Chai
Workmen's Compensation Law.
8. Physician's Name (please print)...
a. Office address.....
Number
b. W.C.B. Authorization Registration No.....................
Street
.....W.C.B. Rating Code..
9.
Date......................... ... ........ 10. Physician's Signature................................. ............".."..""..".
CLAIMANT'S STATEMENT
2. My Social Security Number is:
1. My name is....................."
(Please Print)
First
Middle
Lost
3. Address.......
FIRST FOLD HERE
City or Town
State
Tel. No.........
........"..... 4. My age is.................... 5. Married (check one)
YES
| NO
6. My disability is (If injury, also state how, when and where it occurred)...
7. I became disabled on....
Day
.....;;....."...... a. I worked on that day YES NO
b. I have since worked for wages or profit |YES NO If "Yes", give dates........
8. Give name of last employer. If more than one employer during last eight (8) weeks, name all employers.
Employer's
Dates of Employment
Through
Average
Business Name
Business Address
From
Weekly
Mo .
Yr. Mo.
Day Yr.
Wages
9. My job is or was........
Occupation
Badge or Clock No.""
10. For the period covered by this claim, I have received or am claiming:
a. Wages, Salary or Separation Pay YES No
b. Damages for Personal Injury
YES
NO
c. Benefits under a Workmen's Compensation Law or similar Law.......
NO
d. Unemployment Insurance Benefits.
YES
If "Yes" is checked in any of the items a, b, c or d, fill in the following:
Received or claimed from......
.. For the Period..
Date
...to..
Data
I1. I have received disability benefits for another period or periods of disability within the 52 weeks immediately before my present
disability began.............
...".'.. YES NO
12. I have read the instructions on the reverse side. I hereby claim Disability Benefits and certify that for the period covered by
this claim I was disabled; and that the foregoing statements, including any accompanying statements, are to the best of my
knowledge true and complete.
Claim signed on........
Date
ADDRESS AND MAIL THIS CLAIM TO YOUR LAST EMPLOYER OR HIS INSURANCE COMPANY
DB-450 (1-68)
. SEE IMPORTANT INSTRUCTIONS ON REVERSE SIDE
locuments ucsf.edu/docs/zmwm02

Answer the question using only the OCR text from a single document page. Return only the answer, with no explanation. Preserve the answer wording from the OCR text when possible.