Form Lc 5012 14 – Fill Out and Use This PDF

The LC 5012 14 form, formally known as the Notice and Proof of Claim for Disability Benefits (DB-450), is a critical document for individuals experiencing sickness or disability during employment or within four weeks after employment termination. It serves as a detailed request to obtain disability benefits, guiding the claimant through precise instructions on completion and submission. Specifically, it requires information on the claimant’s employment history, the nature of their disability, and comprehensive statements from both the claimant and their health care provider.

For anyone navigating the complexities of claiming disability benefits, understanding and accurately completing this form is essential. Ensure your claim is processed efficiently by clicking the button below to fill out the form correctly.

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Form Lc 5012 14 PDF Details

The LC 5012 14 form, also known as the DB-450 (3-97) Notice and Proof of Claim for Disability Benefits, plays a pivotal role in the process of claiming disability benefits, particularly for individuals who find themselves sick or disabled while employed or within four weeks after their employment ends. The form requires diligent completion by both claimants and their health care providers to ensure accurate and timely submissions. Claimants must meticulously fill out Part A, while health care providers complete Part B, detailing the diagnosis, symptoms, treatment dates, and the likelihood of the disability being related to employment. Moreover, the document underscores the importance of accuracy and honesty in reporting, as any attempt to present false information is subject to criminal penalties, including fines and possible imprisonment. It's crucial for claimants to submit this form within thirty days of disability onset to either their last employer or the employer's insurance carrier, emphasizing the importance of maintaining a personal copy for records. Additionally, the form embodies provisions for union members, integrating specific fields regarding union affiliation. This comprehensive approach ensures that all necessary information is captured seamlessly, facilitating the processing of claims and the determination of eligibility for disability benefits.

Question	Answer
Form Name	Form Lc 5012 14
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	CERCANA, NYS, RELACIONADAS, LC-5012-14

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Claimant's Signature

Name of Union and Local Number, if Member

THE HARTFORD

NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS

DB-450 (3-97)

CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY

1.USE THIS FORM IF YOU BECOME SICK OR DISABLED WHILE EMPLOYED OR IF YOU BECOME SICK OR DISABLED 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 PART A 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 IT IN YOUR BEHALF. IN THAT EVENT, THE NAME, ADDRESS AND REPRESENTATIVE'S RELATIONSHIP TO YOU SHOULD BE NOTED UNDER THE SIGNATURE.

4. DO NOT MAIL THIS CLAIM UNLESS YOUR HEALTH CARE PROVIDER COMPLETES AND SIGNS PART B THE "HEALTH CARE PROVIDER'S STATEMENT."

5.YOUR COMPLETED CLAIM SHOULD BE MAILED WITHIN THIRTY (30) DAYS AFTER YOU BECOME SICK OR DISABLED TO YOUR LAST

EMPLOYER OR YOUR LAST EMPLOYER'S INSURANCE COMPANY.

6.MAKE A COPY OF THIS COMPLETED FORM FOR YOUR RECORDS BEFORE YOU SUBMIT IT.

PART A CLAIMANT'S STATEMENT (Please print or Type ) ANSWER ALL QUESTIONS

1.	My name is				SOCIAL SECURITY NUMBER
		First	Middle	Last
2.	My address is
2.	My address is	Number	Street	City or Town	State	Zip Code	Apt. No.
		Number	Street	City or Town	State	Zip Code	Apt. No.

3. Tel. No.

4. My age is

5. Married (Check one)

6.My disability is (If injury, also state how, when and where it occurred)

Yes

7. I became disabled on

Month

b. I have since worked for wages or profit

Day

Yes

a. I worked on that day

Year

No If "Yes," give dates

Yes

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

	EMPLOYER'S		DATES OF EMPLOYMENT
BUSINESS NAME	BUSINESS ADDRESS	TELEPHONE NO.	FROM	THROUGH
BUSINESS NAME	BUSINESS ADDRESS	TELEPHONE NO.
			MO. DAY YR.	MO. DAY YR.

AVERAGE WEEKLY

WAGES

(Include Bonuses, Tips, Commissions, Reasonable Value of Board, Rent, etc.)

9. My job is or was

Occupation

10. For the period of disability covered by this claim

a. Are you receiving wages, salary or separation pay:

Yes

b. Are you receiving or claiming:

(1)

.............................................................................................Workers' Compensation for work-connected disability

Yes

(2)

........................................................................................................................................Unemployment Insurance Benefits

Yes

(3)

Damages for personal injury

Yes

(4)

Benefits under the Federal Social Security Act for long-term disability

Yes

IF 'YES" IS CHECKED IN ANY OF THE ITEMS IN 10a OR 10b, COMPLETE THE FOLLOWING:

I have

received

claimed from

for the period

Date

11. I have received disability benefits for another period or periods of disability within the 52 weeks immediately before my

present

disability began:

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

Yes

If "Yes," fill in the following: I have been paid by

From

Date

12.I have read the instructions above. 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.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWL- EDGE 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 FINES AND IMPRISONMENT.

Claim signed on

Date

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

IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS, CONTACT THE NEAREST OFFICE OF THE NYS WORKERS' COMPENSATION BOARD, OR WRITE TO: WORKERS' COMPENSATION BOARD, DISABILITY BENEFITS BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241

SI TIENE DUDAS RELACIONADAS CON LA RECLAMACION DE BENEFICIOS POR INCAPACIDAD, COMUNIQUESE CON LA OFICINA MAS CERCANA DE LA JUNTA DE COMPENSACION OBRERA DE NUEVA YORK, O ESCRIBA A: WORKERS' COMPENSATION BOARD, DISABILITY BENEFITS BUREAU, 100 BROADWAY- MENANDS, ALBANY, NY 12241

HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERSE

LC-5012-14 (DB-450 (3-97)

NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS

IMPORTANT: USE THIS FORM ONLY WHEN THE CLAIMANT BECOMES SICK OR DISABLED WHILE EMPLOYED OR BECOMES SICK OR DISABLED WITHIN FOUR (4) WEEKS AFTER TERMINATION OF EMPLOYMENT. OTHERWISE USE GREEN CLAIM FORM DB-300.

PART B HEALTH CARE PROVIDER'S STATEMENT (Please Print or Type)

THE HEALTH CARE PROVIDER'S STATEMENT MUST BE FILLED IN COMPLETELY AND THE FORM MAILED TO THE INSURANCE CARRIER OR SELF-INSURED EMPLOYER, OR RETURNED TO THE CLAIMANT WITHIN SEVEN DAYS OF THE

RECEIPT OF THE FORM. For item 7d. give approximate date. Make some estimate. If disability is caused by or arising in connection

with pregnancy, enter estimated delivery date under "Remarks."


1.	Claimant's Name	2. Age	3.		male
1.	Claimant's Name	2. Age	3.		male
4.	Diagnosis/Analysis			Diagnosis Code
	a. Claimant's Symptoms

female

b.Objective Findings

Claimant hospitalized?

Yes

From

CPT Code

Operation indicated?

Yes

a. Type

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 be able to perform usual work......................................................

(Even if considerable question exists, estimate date. Avoid use of terms , such as unkown or undetermined.)

8. 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 Workers' Compensation Board?

Yes

Remarks: (attach additional sheet, if necessary)

(If disability is pregnancy related, please enter estimated delivery date.)

I affirm that

Chiropractor

Physician

Psychologist

Licensed in the State of

License Number

I am a

Dentist

Podiatrist

Nurse-Midwife

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 FINES AND IMPRISONMENT.

Health Care Provider's Signature

Date

Health Care Provider's Name (Please print.)

Tel. No.

Office Address

Number

Street

City or Town

State

Zip Code

Employer's Statement

Policy Number:

Employee's Full Name (as shown on Social Security card):

S.S. Number:

Employee's Address:

Date of Birth:

Employee's Occupation:

Date employed:

Full Time

Part Time

Is employee a Union member?

Yes

Check days normally worked:

Mon.

Tues.

Wed.

Thurs.

Fri.

Sat.

Sun.

If "Yes," is employee eligible for Union benefits?

Yes

If Part Time, give particulars:

Date employee last worked:

Date employee returned to work:

EARNINGS 8 WEEKS PRIOR TO DISABILITY

(Including the week in which the disability began)

Were wages continued during disability?

Yes

No. Days

Were wages Sick pay?

Yes

From:

To:

Month

Day

Year

Worked

Amount

Were wages Vacation pay?

Yes

From:

To:

Is reimbursement requested?

Yes

Is disability due to job?

Yes

If "Yes," has a compensation

been

Yes

claim

filed?

Indicate Weekly Value of Board, Lodging and Tips:

Employer's Name:

Employer's Identification No.:

Is employee enrolled in a Hartford Long Term Disability Plan?

Yes

If "Yes," effective date:

Total

Based on the employer/employee premium contributions made over the last 3 years, what percentage of the Weekly Disability

LTD

benefit is considered taxable? (See Section 7 of IRS Publication 15-A for information on determining the taxable percentage.) If blank, we will

assume the benefit is 100% taxable.

Is this employee currently covered by Social Security?

Yes

If "No," state grounds for exemption:

Address:

Telephone No.:

Signed by:

Title:

Date:

DB-450 (3-97)

Reverse

THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

LC-5012-14 Printed in U.S.A.

How to Edit Form Lc 5012 14 Online for Free

By using the online PDF editor by FormsPal, it is easy to complete or edit CLAIMANT right here. The editor is continually updated by our team, receiving powerful features and turning out to be greater. Should you be looking to start, this is what it's going to take:

Step 1: First of all, access the editor by clicking the "Get Form Button" above on this site.

Step 2: With the help of our online PDF editing tool, you're able to accomplish more than merely fill in blank fields. Express yourself and make your documents seem faultless with custom text added, or modify the file's original input to excellence - all accompanied by an ability to incorporate your own pictures and sign the PDF off.

It's straightforward to complete the form using this detailed guide! Here's what you have to do:

1. The CLAIMANT necessitates specific details to be typed in. Ensure that the next blank fields are finalized:

2. Once your current task is complete, take the next step – fill out all of these fields - For the period of disability, Yes Yes Yes Yes, No No No No, I have received claimed from, for the period, Date, Date, I have received disability, Yes, If Yes fill in the following I, From, Date, Date, I have read the instructions, and ANY PERSON WHO KNOWINGLY AND WITH with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

It's simple to make a mistake while completing the Yes, consequently make sure that you reread it before you decide to submit it.

3. Completing PART B HEALTH CARE PROVIDERS, Claimants Name, DiagnosisAnalysis a Claimants, b Objective Findings, Age, male, female, Diagnosis Code, Claimant hospitalized, Yes Operation indicated Yes, From, a Type, Enter dates for the following a, CPT Code, and Month is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

4. You're ready to fill out this next segment! Here you'll have all of these Health Care Providers Signature, Date, Tel No, Office Address, Number, Street, City or Town, State, Zip Code, Employers Statement, Employees Full Name as shown on, Policy Number SS Number, Employees Address Employees, Yes, and To To form blanks to fill out.

Step 3: Glance through what you've typed into the form fields and then click on the "Done" button. Go for a free trial option with us and gain immediate access to CLAIMANT - download, email, or edit from your FormsPal cabinet. We don't sell or share any information that you type in while dealing with documents at our website.

Form Lc 5012 14 – Fill Out and Use This PDF

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