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Subject Number 046-1650 Updated Disability Benefits Forms

Board Bulletins and Subject Numbers

December 29, 2023

To conform to the updated disability benefits regulations taking effect January 1, 2024, the New York State Workers' Compensation Board (Board) has posted the updated Notice and Proof of Claim for Disability Benefits (Form DB-450) and the new Notice of Denial of Claim for Disability Benefits (Form DB-DEN) will be available upon request. Please note that the failure of the employer to fully or adequately complete the employer's information section (Part C) on the DB-450 form is not a valid basis for denial of the claim.

The DB-DEN form must be issued within 18 days of receipt of claim or the claimant's first day of disability, unless the Notice of Total or Partial Rejection of Claim for Disability Benefits (Form DB-451) is issued within this time frame. If the DB-451 form is issued within 18 days as described, the DB-DEN form does not need to be issued. Neither Form DB-451 or Form DB-DEN will be available for download on the Board's website, rather, insurers and Board-approved self-insurers may request them by contacting the Board's Forms Department.

The Board has also revised the New York State Disability Benefits Statement of Rights (Form DB-271S) to simplify the language and ensure conformity with other Board-issued materials.

Please be reminded that when an employee is absent from work for more than seven consecutive days due to a disability, the employer must provide the employee with the DB-271S form within five business days after the employee's seventh consecutive day of absence, or within five business days after the employer has received notice that the employee's absence is due to disability, whichever is later.

For more information regarding the new and updated forms, email Regulations@wcb.ny.gov.

Clarissa M. Rodriguez
Chair