Lc 5012 16 Form – Fill Out and Use This PDF

The LC 5012 16 form serves as a crucial notice and proof of claim for individuals seeking disability benefits either after falling sick or becoming disabled while employed or within four weeks after their employment termination. It lays out comprehensive instructions for claimants, emphasizing the importance of accurate completion and timely submission to ensure benefits are correctly and swiftly processed. For individuals navigating the complexities of claiming disability benefits, understanding every part of this form is fundamental to securing the support they need during challenging times. Click the button below to start filling out your form and move one step closer to obtaining your benefits.

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Lc 5012 16 Form PDF Details

In the realm of employment and health, navigating the process to claim disability benefits after an unforeseen illness or injury while employed, or shortly thereafter, can seem daunting. The LC 5012 16 form, officially known as the "Notice and Proof of Claim for Disability Benefits," serves as a critical bridge for employees in this predicament. Designed with the claimant's ease in mind, it mandates the careful completion of two main parts: Part A, the "Claimant's Statement," which requires detailed personal and employment information, and Part B, the "Health Care Provider's Statement," which must be filled out by the health care provider to verify the claimant’s condition. In order to steer clear of common pitfalls, it emphasizes the importance of accuracy in detailing the disability, including the exact dates and specifics of the illness or injury, and underscores the significance of submitting the form within 30 days post-disability onset. Moreover, the form includes a warning against fraudulent claims, highlighting the legal consequences thereof. Accompanied by a comprehensive set of instructions, this form is pivotal for employees seeking to navigate the complexities of claiming disability benefits, ensuring they’re informed about the requirements for a valid claim, from signing and dating the document to making a copy for personal records. This introductory guide aims to untangle the complexities and elaborate on key facets of the LC 5012 16 form, providing claimants with the knowledge needed to proceed with their claim confidently.

Question	Answer
Form Name	Lc 5012 16 Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	db 450, lc 5012 form 2019, lc dbl 450 download, lc dbl 450 disability

Form Preview Example

NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS

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 FORM, YOUR REPRESENTATIVE MAY SIGN IT ON 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: (First, Middle & Last)

2. Social Security Number:

3. Date of Birth:

My Address : (Number, Street, City or Town, State & Zip Code)

5. My Telephone Number:

(

)

Martial Status: : (Check one)

7. My disability is : (if injury, also state how, when and where it occurred)

Married

Single

I became disabled on :

a. I worked on that day:

Yes

b. I have since worked for wages or profit:

Yes

If "Yes", give dates:

Month/ Day/ Year

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

Employer's

Dates of Employment

Average Weekly Wages

(Include Bonuses, Tips,

Business Name

Business Address

Phone Number

From

Through

Commissions, Reasonable

(

)

Month/Day/Year

Month/ Day/Year

Value of Board, Rent, etc.)

(

)

(

)


10. My job is or was: (Occupation)			Name of Union and Local Number, if member:

11. For the period of disability covered by this claim:				Yes	No
a. Are you receiving wages, salary or separation pay:
b. Are you receiving or claiming:				Yes	No
(1) Workers' compensation for work-connected disability

(2) Unemployment Insurance Benefits				Yes	No
(3) Damages for personal injury				Yes	No
(4)	Benefits under the Federal Social Security Act for long-term disability			Yes	No
IF "YES" IS CHECKED IN ANY OF THE ITEMS IN 11a OR 11b, COMPLETE THE FOLLOWING
I have	received	claimed	From	For the period		To

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

disability began:	Yes	No	From	To
If "Yes" fill in the following:		I have been paid by:

13.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 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.

Electronic Funds Transfer (EFT) is our standard method of payment. When making our claim decision we may contact you to obtain your banking information.

Claim signed on:	Claimant's Signature:
If signed by other than claimant, print below: name, address, and relationship of representative:


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

HEALTH CARE PROVIDER MUST COMPLETE PART B ON REVERSE

LC-5012-16 DB-450

Page 1 of 3

09/2010

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". (Even if considerable question exists, estimate date. Avoid using terms such as unknown or undetermined).

Claimant's Name:

2. Date of Birth:

3. Sex:

Male

Female

Diagnosis/Analysis:

Diagnosis Code:

a. Claimant's Symptoms:

b. Objective Findings:

Claimant Hospitalized?

Yes

From

Operation Indicated?

Yes

a. Type

b. Date

7.Enter Dates for the Following:

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:

e. If disability is pregnancy related, please estimate delivery date:

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	No
Remarks: (attach additional sheet, if necessary)

I affirm that I am a:		Chiropractor	Physician		Psychologist	Dentist	Podiatrist	Nurse-Midwife

License Number:				Licensed in the State of:

Health Care Provider's Signature:	Date:

Health Care Provider's Name: (Please Print)	Telephone Number:
	(	)

Office Address: (Number, Street , City or Town, State & Zip)

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.

LC-5012-16 DB-450

Page 2 of 3

09/2010

NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS

PART C - EMPLOYER'S STATEMENT

Employee's full name: (As shown on Social Security Card)

Social Security Number:

Employee's Address: (Street, City, State & Zip Code)

Date of Birth:

Date of employment:

Check days normally worked:

Full Time

Part Time

Sun.

Mon.

Tues.

Wed.

Thurs.

Fri.

Sat.

If Part Time, give particulars:

Is employee a Union member?

Yes No

Date employee last worked:

If "Yes," is employee entitled to Union Benefits			Occupation:
Yes	No
Date employee returned to work:		Were wages continued during disability?
		Yes	No

Were wages Sick pay?

Were wages Vacation pay?

Yes

From:

To:

Yes

From

Is reimbursement requested?

EARNINGS 8 WEEKS PRIOR TO AND INCLUDING THE DATE

Yes

LAST WORKED PRIOR TO THE ONSET OF DISABILITY.

No. Days

Month

Day

Year

Worked

Amount

Is disability due to job?

Yes

If "Yes," has a compensation claim been filed?

Yes

Indicate Weekly Value of Board, Lodging and Tips:

Is this employee currently covered by Social Security?

Yes

Total

If "No," state grounds for exemption:

Is employee enrolled in a Hartford Long Term Disability Plan?

Yes

If "Yes," effective date.

Hartford NY Disability Policy Number:

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

benefit it is considered taxable? % LTD % (See section 6 of IRS Publication 15-A for information on determining the taxable percentage.) (If blank, we will code the benefit as 100% taxable until you submit written notice of the correct taxable %.)


Employer's Name:	Employer's Identification Number:

Address: (Street, City, State & Zip Code)	Telephone Number:
	(	)

Signed by:

Date:

Title:

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

LC-5012-16 DB-450

Page 3 of 3

09/2010

How to Edit Lc 5012 16 Form Online for Free

When you need to fill out db450, it's not necessary to install any applications - just try our online PDF editor. To maintain our editor on the forefront of practicality, we aim to integrate user-oriented features and improvements regularly. We're routinely pleased to get feedback - help us with reshaping PDF editing. It merely requires several basic steps:

Step 1: Click the "Get Form" button above on this page to get into our tool.

Step 2: As soon as you start the PDF editor, you will find the document made ready to be completed. In addition to filling in various blanks, you may also perform many other actions with the form, including adding custom words, modifying the original textual content, adding graphics, affixing your signature to the document, and more.

As for the blanks of this precise PDF, this is what you want to do:

1. It is very important complete the db450 accurately, hence be mindful while filling in the sections including all these blanks:

2. Just after filling out the previous part, go to the next part and complete all required details in these blanks - a Are you receiving wages salary, Workers compensation for, Yes No Yes No Yes No Yes No, IF YES IS CHECKED IN ANY OF THE, I have received claimed I have, From, For the period, If Yes fill in the following I, From To, I have read the instructions, Claim signed on If signed by other, Claimants Signature, IF YOU HAVE ANY QUESTIONS ABOUT, SI TIENE DUDAS RELACIONADAS CON LA, and LC DB.

3. In this specific part, have a look at Claimants Name, Date of Birth, Sex, DiagnosisAnalysis a Claimants, b Objective Findings, Claimant Hospitalized Yes No, From To, Male Female, Diagnosis Code, Operation Indicated Yes No, a Type, b Date, Enter Dates for the Following, Date of your first treatment for, and b Date of your most recent. All these need to be taken care of with highest accuracy.

4. The following section comes with all of the following fields to consider: I affirm that I am a, Chiropractor, Physician Psychologist, Dentist, Podiatrist, NurseMidwife, License Number, Licensed in the State of, ANY PERSON WHO KNOWINGLY AND WITH, Health Care Providers Signature, Date, Health Care Providers Name Please, Office Address Number Street City, Telephone Number, and HIPAA NOTICE In order to.

db 450 completion process shown (portion 4)

Be very mindful when filling in Health Care Providers Name Please and Date, because this is the part in which a lot of people make some mistakes.

5. As a final point, the following final segment is what you will need to complete before using the form. The blanks in this case include the following: PART C EMPLOYERS STATEMENT, Social Securit y Number, Employees Address Street City, Date of Birth, Date of employment, Full Time, Part Time, Check days normally worked, Sun Mon Tues Wed Thurs Fri Sat, If Part Time give particulars, s employee a Union member I, Yes No, If Yes is employee entitled to, Occupation, and Yes No.

PART C EMPLOYERS STATEMENT, If Yes is employee entitled to, and Yes No of db 450

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Lc 5012 16 Form – Fill Out and Use This PDF

Lc 5012 16 Form PDF Details

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