DB 450 Form – Fill Out and Use This PDF

DB 450 Form PDF Details

The DB 450 form, formally known as the Notice and Proof of Claim for Disability Benefits, is a New York State document required when an employee files a short-term disability claim. New York law requires most private employers to carry disability benefits insurance, and the NYSIF (New York State Insurance Fund) is the primary carrier for many of these policies. The form applies to employees who are disabled due to illness, injury, pregnancy, or off-the-job accidents.

Who completes each part of the DB 450 form

• Part A (Claimant): The employee provides personal details, employment dates, and information about the disability, including the start date and nature of the illness or injury.
• Part B (Health Care Provider): The attending physician or hospital certifies the disability, provides a diagnosis, and indicates the expected recovery period. A note from the treating doctor is required.
• Part C (Employer): The employer verifies employment, salary, and insurance carrier information. This section must be completed even if the employer disputes the claim.

Disability benefits under this program cover non-work-related illness, injury, or pregnancy. New York's Paid Family Leave (PFL) program operates separately from disability benefits, but the leave periods may overlap for qualifying events such as a new child or a family member's serious illness. Submit the completed form to your employer or insurance carrier within 30 days of your first day of disability. Late filing may reduce your paid benefits.

Employees who cannot return to work due to a serious illness may also need a Disability Letter from Doctor or a separate Disability Claim Form. For workers covered under a union plan, the 1199 Notice and Proof of Claim for Disability may apply instead.