Please confirm with your employer or the Worker's Compensation Board that your employer's disability benefits carrier is NYSIF. If so, please complete and submit a NYSIF DB-450 form to NYSIF. Use this form if you become sick or disabled while employed or if you become sick or disabled within four weeks after your last day worked.
If you become sick or disabled after having been unemployed more than four weeks, NYSIF would not be the proper carrier to handle your claim request. Follow the “How to File a Claim” instructions provided by the New York State Workers’ Compensation Board to submit your claim with the NYS Special Fund for Disability Benefits.
Part A is completed by the claimant. Be sure to answer all questions completely and sign the front of the form. Write clearly. Incomplete or unsigned forms may be returned.
Part B is completed by the health care provider. Be sure your medical provider indicates the estimated date you may return to work. Do not indicate "unknown" or "undetermined."
Part C is completed by the employer and provides the necessary information NYSIF uses to process the claim.
Your completed claim form should be submitted to your most recent employer or NYSIF within 30 days after you become sick or disabled.
Mail completed NYSIF DB-450 forms to:NYSIF Document Control Center
1 Watervliet Avenue Ext.
Albany, NY 12206
You may also fax your NYSIF DB-450 to 518-437-5201. Be sure to keep a copy for your records.