A Disability Claim must be reported within 30 days of the employee becoming disabled.

The employee must be under the care of a physician, chiropractor, podiatrist, psychologist, dentist, or certified nurse midwife in order to qualify for benefits.  The health care provider must complete and sign the “Health Care Provider’s Statement” as proof of the disability.

The employee should complete the “Claimant’s Statement” and the “Employers Statement” must be completed before sending the form on to the insurance company.

You may download the DB-450 form below, ensure that all sections are completed and fax to us at 516-766-3606
Attention: Claims Department.

Click here for DB-450 Form

Following  is some useful information regarding disability claims.

Eligibility:  To be eligible, an employee must have four (4) consecutive weeks of covered employment.

Benefits (1998):  Maximum - $170 a week; Minimum - $20 a week; based on 50% of the average weekly wage for the eight (8) weeks immediately preceding disability, including the week of disability.

Exception:  If wages are less than $20 a week, the benefit will be the average weekly wage.  One day’s benefit is equal to that fractional part of the week based on the number of days the employee normally works.

Note:   If the employer continues to pay wages during disability, no benefits are payable to the claimant; however, the employer can request reimbursement and benefits will be paid to the employer for such period.

Elimination Period:  Seven (7) days for both accident and sickness.

Benefit Period:  Maximum - Twenty-six weeks within any 52 week period or 26 weeks for any one continuous disability.  Normal benefit provided for pregnancy is 6 weeks; 8 weeks for a caesarian delivery.