P.O.

Box 25339
Farmington, NY 14425 New York State
phone 800-477-0087
claims@sslicny.com NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
You must answer all questions in Part A and questions 1 through 3 in Part B. Health care providers must complete Part B on page 2. Employer must
complete part C.
PART A - CLAIMANT'S INFORMATION (Please Print or Type)
1. First Name: Last Name: MI:
2. Mailing Address (Street & Apt. #):
City: State: Zip:
3. Daytime Phone #: Email Address:
4. Social Security #: / / 5. Date of Birth: / / 6. Gender: Male Female
7. Describe your disability (if injury, also state how, when, and where it occurred):

8. Date you became disabled: / /

Did you work on that day?: Yes No
Have you recovered from this disability?: Yes No If Yes, date you were able to return to work: / /
Have you since worked for wages or profit?: Yes No If Yes, list dates:
9. Name of last employer prior to disability. If more than one employer in previous eight (8) weeks, name all employers. Average
Weekly Wage is based on all wages earned in last eight (8) weeks worked.
Average Weekly Wage
LAST EMPLOYER PRIOR TO DISABILITY PERIOD OF EMPLOYMENT (Include Bonuses, Tips,
Commissions, Reasonable
Firm or Trade Name Address Phone Number First Day Last Day Worked Value of Board, Rent, etc.)

Mo. Day Yr. Mo. Day Yr.

Average Weekly Wage
OTHER EMPLOYER (during last eight (8) weeks) PERIOD OF EMPLOYMENT (Include Bonuses, Tips,
Commissions, Reasonable
Firm or Trade Name Address Phone Number First Day Last Day Worked Value of Board, Rent, etc.)

Mo. Day Yr. Mo. Day Yr.

Mo. Day Yr. Mo. Day Yr.

10. My job is or was: 11. Union Member: Yes No If "Yes":

Occupation Name of Union or Local Number
12. Were you claiming or receiving unemployment prior to this disability? Yes No
If you did not claim or if you claimed but did not receive unemployment insurance benefits after LAST DAY WORKED, explain
reasons fully:

If you did receive unemployment benefits, provide all periods collected:

13. For the period of disability covered by this claim:

A. Are you receiving wages, salary or separation pay? Yes No
B. Are you receiving or claiming:
1. Unemployment Benefits Yes No 2. Paid Family Leave? Yes No
3. Workers' compensation for work-connected disability? Yes No
4. No-Fault motor vehicle accident? Yes No or personal injury involving third party? Yes No
5. Long-term disability benefits under the Federal Social Security Act for this disability: Yes No
IF "YES" IS CHECKED IN ANY OF THE ITEMS IN 13, COMPLETE THE FOLLOWING:
I have: received claimed from for the period: / / to: / /
14. In the year (52 weeks) before your disability began, have you received disability benefits for other periods of disability? Yes No
If yes, Paid by: from: / / to: / /
15. In the year (52 weeks) before your disability began, have you received Paid Family Leave? Yes No
If yes, Paid by: from: / / to: / /
16. If you became disabled while employed or within four weeks of your last day worked, did your employer provide you with your rights
under Disability Law within 5 days of your notice or request for disability forms? Yes No
I hereby claim Disability Benefits and certify that for the period covered by this claim I was disabled. The foregoing statements, including any accompanying statements are,
to the best of my knowledge, true and complete.

Claimant's Signature Date

An individual may sign on behalf of the claimant only if he or she is legally authorized to do so and the claimant is a minor, mentally incompetent or incapacitated. If signed by
other than claimant, print information below and complete and submit Form OC-110A, Claimant's Authorization to Disclose Workers' Compensation Records.

On behalf of Claimant Address Relationship to Claimant

DB-450 (1-20) Page 1 of 2

 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 RETURN TO THE CLAIMANT WITHIN SEVEN (7) DAYS OF RECEIPT OF THIS FORM. For item 7-d, you must give estimated
date. If disability is caused by or arising in connection with pregnancy, enter estimated delivery date in item 9. INCOMPLETE ANSWERS MAY DELAY
PAYMENT OF BENEFITS.
1. Last Name: First Name: MI:
2. Gender: Male Female 3. Date of Birth: / /
4. Diagnosis/Analysis: Diagnosis Code:
a. Claimant's symptoms:

b. Objective findings:

5. Claimant hospitalized?: Yes No From: / / To: / /

6. Operation indicated?: Yes No a. Type b. Date / /
7. 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.)
e. If pregnancy related, please check box and enter the date
estimated delivery date OR actual 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 Board? Yes No

I certify that I am a:

(Physician, Chiropractor, Dentist, Podiatrist, Psychologist, Nurse-Midwife) Licensed or Certified in the State of License Number

Health Care Provider's Printed Name Health Care Provider's Signature Date

Health Care Provider's Address Phone #

Part C - EMPLOYER'S STATEMENT

1. Employee’s Name: 2. Soc. Sec. #:

3. Employee’s Address:
Number Street Apartment Number City / Town State Zip Code
4. Employee’s Occupation: 5. Date of Hire: 6. Status: Full Time Part Time
7. Is the Claimant an: Employee Owner High School Student 7a. Date of Birth
8. Indicate the employee’s normal work schedule: Mon Tues Wed Thur Fri Sat Sun
9. If the employee is no longer in your employ, explain why: Quit Fired Laid Off Other (explain)
10. Date Employee last worked: 10a. Do you expect to rehire him/her? YES NO
11. Date Employee returned to work: Weekly Wages 8 Weeks prior to Last Day Worked Before Disability
12. Are you paying wages or sick time: ................................................................ YES NO (include value of Board, Lodging, and Tips if any)
Week Ending No. of Days
a. If YES, time period paid: GROSS WEEKLY WAGES
Month Day Year Worked
b. Are you requesting reimbursement for this time period? ............................... YES NO
1.
13. Is Employee receiving or claiming Unemployment Ins? ................................ YES NO
2.
14. Is Employee receiving or claiming Workers’ Comp. Ins? .............................. YES NO
3.
15. Did this Disability occur as a result of employment? ..................................... YES NO
4.
16. Is Employee in a Union proving MONETARY DISABILITY BENEFITS? ..... YES NO
17. Are you aware of other employment claimant may have? ............................ YES NO 5.
18. Has the employee received DBL or PFL benefits within the past 52 weeks? YES NO 6.
19. TAXABLE PERCENTAGE % 7.

POLICY NUMBER: 8.

EMPLOYER INFORMATION: TOTAL

Employer Name: Employer Address:

Phone: Fax: E-mail:
Print Name: Sign: Title: Date:
After Parts A, B, & C are COMPLETED, Do one of the following: SSLICNY Phone: 800-477-0087 or 585-398-2340
Mail to: SSLICNY, P.O. Box 25339 Farmington, NY 14425 or Fax to: 585-398-2854 or E-mail to: claims@sslicny.com
DB-450 (1-20) Page 2 of 2