Db 300 Form – Fill Out and Use This PDF

The DB-300 form is a critical document issued by the New York State Workers' Compensation Board for unemployed individuals seeking disability benefits after becoming sick or disabled four weeks following their last employment. This form serves as both a notice and proof of claim, requiring detailed information about the claimant’s condition, previous employment, and the specifics of their disability. Understanding the importance of submitting this form promptly and accurately can significantly impact the approval process for disability benefits.

To facilitate your claim, ensure the form is filled out comprehensively, including necessary documentation about your medical condition from a healthcare provider. For assistance in completing the DB-300 form or to submit your claim, click the button below.

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Db 300 Form PDF Details

In navigating the landscape of workers' compensation in New York, the DB-300 form emerges as a critical document for individuals facing sickness or disability after a period of unemployment extending beyond four weeks. Originating from the New York State Workers' Compensation Board, this form serves as a notice and proof of claim specifically tailored for unemployed claimants who find themselves incapacitated by illness or injury during their job search. The procedure mandates meticulous adherence to instructions, requiring claimants to provide personal information, including their social security number, name, address, and a detailed account of their disability. Additionally, it necessitates information about their previous employment, union membership, if any, and a comprehensive account of any unemployment benefits claimed or received prior to the disability. The form is divided into two primary parts: the claimant's statement and a health care provider's statement, which must be completed and submitted to the Workers' Compensation Board in Albany, NY. This process not only facilitates the efficient processing and accurate record-keeping of claims but also underscores the state's commitment to protecting individual privacy, as detailed in the accompanying HIPAA notice. Failure to provide the requested information can delay the processing of claims, highlighting the importance of the DB-300 form in ensuring that those suffering from disability while unemployed receive the benefits to which they are entitled under New York State law.

Question	Answer
Form Name	Db 300 Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	db 300 disability form, form db 300, db300 form, claim form db 300

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STATE OF NEW YORK

WORKERS' COMPENSATION BOARD

DISABILITY BENEFITS BUREAU

100BROADWAY-MENANDS ALBANY, NY. 12241 - 0005

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.

PART A-CLAIMANT'S STATEMENT (Please Print or Type)

a. My Social Security Number is:

My name is

(Please Print)

First

Middle

Last

a. Address

Number

Street

City or Town

State

Zip Code

Apt. No.

b. Tel. No

3. Sex

4. Date of Birth

5. Married

Yes

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?		Yes	No
If "Yes", what was the date you were able to work:		Month	Day	Year

9. My job is or was	10. Union Member?
	Occupation

Yes

No If "Yes",...................................................

Name of Union and Local Number

11. Give name of last employer. If more than one employer during last (8) weeks, name all employers.

	a. LAST EMPLOYER		PERIOD OF EMPLOYMENT			Average Weekly Wage
	a. LAST EMPLOYER		PERIOD OF EMPLOYMENT			(Include Bonuses, Tips
						Commissions, Reasonable
Firm or Trade Name	Address	Telephone No.	First Day	Last day worked		Value of Board, rent, etc.)
Firm or Trade Name	Address	Telephone No.	First Day	Last day worked
			Mo. Day Yr.	Mo. Day	Yr.

	b. OTHER EMPLOYERS (during last eight (8) weeks)
Firm or Trade Name		Address

Telephone No.

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

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

HERE	If signed by other than claimant, print below: name, address, and relationship of representative.
	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

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.

1. Claimant's Name	Middle Initial	2. Date of Birth	3. Sex
First	Middle Initial	Last

4.Diagnosis/Analysis:......................................................................................................................................................................................................

a.Claimant's symptoms:.............................................................................................................................................................................................

b.Objective findings:....................................................................................................................................................................................................

Claimant hospitalized?

Yes

From

Operation indicated?

Yes

a. Type

b. Date

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 again be able to perform work

(Even if considerable question

exists, estimate date. Avoid use of terms such as unknown or undetermined.)

In your opinion, is this disability the result of injury arising out of and in the course of employment or occupational disease?

Yes

No If "Yes", has Form C-4 been filed with the Board?

Yes

Remarks:

I affirm that I am a

Licensed or

License

Certified in the State of

No.:

(Physician, Chiropractor, Dentist, Nurse-Midwife, Podiatrist or Psychologist)

Health Care Provider's Printed Name

..........................................................................

Signature

Date

Office

Tel No

Address

Number

Street

City/town

State

Zip

Signed

CLAIMANT: READ THESE INSTRUCTIONS CAREFULLY - ANSWER ALL QUESTIONS

1. MAKE SURE YOU FILE THE CORRECT CLAIM FORM. This is the correct claim form to use if you become sick or disabled more than four (4) weeks AFTER you last worked.

2. COMPLETED CLAIM FOR DISABILITY BENEFITS. You complete and sign, Part A - Claimant's Statement. (If you are not able to sign

the Claimant's Statement, your representative may sign on your behalf. Place for signing is indicated by on reverse side. Your Health Care Provider completes and signs Part B - Health Care Provider's Statement.

3. FILE YOUR CLAIM FOR DISABILITY BENEFITS PROMPTLY. Your completed claim should be filed (mailed) not later than thirty (30) days after you become sick or disabled. If it is being filed late (more than 30 days after your disability began) attach a statement explaining why you could not file this claim earlier. Make a photocopy of this completed form for your records before you submit it.

Mail this form to:

Workers' Compensation Board

Disability Benefits Bureau

100 Broadway - Menands

Albany, NY, 12241-0005

Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 U.S.C. Sec. 552a).

The Workers’ Compensation Board’s (“Board”) authority to request personal information from claimants is derived from Sections 20 and 142 of the Workers’ Compensation Law. This information is collected to assist the Board in processing claims in an efficient manner and to help it maintain accurate claim records.

The Board is strongly committed to protecting the confidentiality of all personal information that it collects. Such information will be disclosed within the agency only to Board personnel and agents in furtherance of their official duties. Personal information will be disclosed outside the agency only in accordance with applicable state and federal law.

The Board’s Director of Operations, located at 100 Broadway, Menands, New York 12241 (518-474-6674), is primarily responsible for the maintenance of agency records containing personal claimant information.

Failure to provide the information requested on this form will not result in the denial of your claim, but may delay the processing of your claim. The voluntary release of your social security number enables the Board to ensure that information is associated with, and quick action is taken on, your claim.

HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information.

Disclosure of Information: The Board will not disclose any information about your case to any unauthorized party without your consent. If you choose to have such information disclosed to an unauthorized party, you must file with the Board an original signed Form OC-110A, Claimant's Authorization to Disclose Workers' Compensation Records, or an original signed, notarized authorization letter. You may telephone your local WCB office to have Form OC-110A sent to you, or you may download it from our web page, www.wcb.ny.gov. It can be found under the heading Common Forms Online. Mail the completed authorization form or letter to the address given on the front of this form.

IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS,	SI TIENE DUDAS RELACIONADAS CON LA RECLAMACION DE BENEFICIOS
	POR INCAPACIDAD, COMUNIQUESE CON LA OFICINA MAS CERCANA DE LA
CONTACT THE NEAREST OFFICE OF THE NYS WORKERS' COMPENSATION
	JUNTA DE	COMPENSACION	OBRERA DE NUEVA YORK, O ESCRIBA A:
BOARD, OR WRITE TO: WORKERS' COMPENSATION BOARD, DISABILITY
	WORKERS'	COMPENSATION	BOARD, DISABILITY BENEFITS BUREAU,100
BENEFITS BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241-0005.	BROADWAY- MENANDS, ALBANY. NY 12241-0005.

DB-300 (2-04) Reverse

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When it comes to blanks of this specific form, here is what you need to do:

1. It's essential to complete the db300 form properly, hence take care while working with the segments including these blanks:

Filling out section 1 in form db 300 ny state disability application

2. Once your current task is complete, take the next step – fill out all of these fields - Were you claiming or receiving, a If Yes give UI Local Office, b If you did not claim or if you, For the period of disability, I hereby claim Disability Benefits, SIGN, HERE, and Claimants Signature Date claim with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

form db 300 ny state disability application completion process shown (portion 2)

3. Completing HERE, Claimants Signature Date claim, Name and addressRelationship, ANY PERSON WHO KNOWINGLY AND WITH, and HEALTH CARE PROVIDER MUST COMPLETE is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Writing part 3 in form db 300 ny state disability application

When it comes to Claimants Signature Date claim and HERE, be certain that you get them right in this current part. These two are definitely the key fields in this form.

4. This next section requires some additional information. Ensure you complete all the necessary fields - PART B HEALTH CARE PROVIDERS, First Middle Initial Last, DiagnosisAnalysis, a Claimants symptoms, b Objective findings, Claimant hospitalized Yes No, Operation indicated Yes No a, ENTER DATES FOR THE FOLLOWING a, MONTH, DAY, YEAR, In your opinion is this, Remarks, Licensed or License I affirm, and Physician Chiropractor Dentist - to proceed further in your process!

Step # 4 in filling out form db 300 ny state disability application

5. The very last notch to complete this PDF form is integral. Make certain to fill in the mandatory blank fields, and this includes Physician Chiropractor Dentist, Health Care Providers Printed Name, Number Street Citytown State Zip, CLAIMANT READ THESE INSTRUCTIONS, Notification Pursuant to the New, The Workers Compensation Boards, The Board is strongly committed to, personnel and agents in, The Boards Director of Operations, containing personal claimant, Failure to provide the information, social security number enables the, and Disclosure of Information The, before finalizing. If not, it could produce a flawed and probably invalid paper!

Disclosure of Information The, The Board is strongly committed to, and CLAIMANT READ THESE INSTRUCTIONS of form db 300 ny state disability application

Step 3: Spell-check all the details you have typed into the blanks and then press the "Done" button. Try a free trial option with us and gain instant access to db300 form - download, email, or edit in your personal account. FormsPal is focused on the personal privacy of our users; we ensure that all personal data going through our system continues to be protected.

Db 300 Form – Fill Out and Use This PDF

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