If you became sick or disabled after having been unemployed for more than four (4) weeks, file with:įile no later than 30 days after becoming sick or disabled.Ĭlaimant's Statement Regarding No Fault or Personal Injury

If you became sick or disabled while employed or you became sick or disabled within four (4) weeks after termination of employment, file with your employer or its insurance carrier. Notice and Proof of Claim for Disability Benefits The table below has the most recent version of each form, and where older versions are no longer accepted, includes the notation 'Only current version accepted.'ĭisability Benefits Forms for Employees Form Number /Īny employee receiving or entitled to receive Social Security retirement benefits may submit this form at any time to waive any and all benefits under the Disability and Paid Family Leave Benefits Law As such, WCB may announce that it will not accept older versions of an updated form after a certain date. These changes are often extensive, and it is important for all stakeholders to use the same form so that information is consistent. WCB periodically releases new versions of certain forms to obtain additional information, streamline processing, and/or make it easier to complete the form. Parties of interest other than the Board must receive both sides of all two-sided forms and all pages of multi-page forms. However, do NOT submit to the Board any sheets that contain only instructions and/or reference material. If this is not possible, submit as separate sheets. Two-sided and multi-page forms are to be printed and submitted to the Board in duplex format. If you still have trouble with the form, please email the Board's Forms Department.

If you have trouble opening a form: (1) download/save the form onto your computer, (2) open Adobe Reader, (3) open the saved file. After the form opens, you may complete the form by typing information on the form before you print it. The Board recommends using the latest version of Adobe Reader which is available as a free download from Adobe's website. If you require assistance with completing these forms, please contact us.įorms are in PDF format.

Nys 2016 extension form