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  • Lc-5012 Dbl-450 Notice Of Proof Of Claim For Disablitity Lc-5012 Dbl-450

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Clear Form 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.

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Short term disability is intended to cover you immediately following a serious illness or injury, and long term disability insurance is intended to maintain income replacement if your condition keeps you out of work past the end of your short term disability benefit period, even to retirement, depending on your plan.

New York employees can receive up to 26 weeks of paid short-term disability benefits per year. If you are injured or you become ill while not on the job, you may be eligible for New York State short-term disability benefits under its Disability Benefits Law (DBL).

Who Is Eligible for New York Short-Term Disability Benefits? In order to be eligible for short-term disability benefits, you must have become injured or ill while not at work but must be employed, or recently employed, at the time of illness or injury.

If you are unable to check your status online, you can call us 1-800-772-1213 (TTY 1-800-325-0778) from 8:00 a.m. to 7:00 p.m., Monday through Friday.

Disability benefits are temporary cash benefits paid to an eligible employee, when they are disabled by an off-the-job injury or illness. Disability benefits are equal to 50 percent of the employee's average weekly wage for the last eight weeks worked, with a maximum benefit of $170 per week (WCL §204).

How it works. Pays a percentage of covered earnings if you can't work for a period of time due to a covered illness or injury. Quick disability claim decisions so you'll receive payment for your claims quickly. The money can be spent any way you'd like–just like you'd use your paycheck.

To file an NY DBL/PFL disability claim, call (866) 274-9887.

If you are using this form because you became disabled after having been unemployed for more than four (4) weeks, your completed claim MUST be mailed to: Workers' Compensation Board, Disability Benefits Bureau, PO Box 9029, Endicott, NY 13761-9029.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232