Completing New York State Disability Form DB-450: Parts A, B, and C

To claim New York State short-term disability benefits, you file the DB-450, “Notice and Proof of Claim for Disability Benefits.” The New York disability form DB-450 has three parts: you complete Part A, your treating provider completes Part B, and your employer completes Part C. The finished form goes to your employer or their disability insurance carrier within 30 calendar days of your first day of disability.¹²

Before You File

The DB-450 is for off-the-job illness, injury, or pregnancy. If a work-related injury or illness caused your condition, you file a workers’ compensation claim instead. You also must be under the active care of a physician, chiropractor, podiatrist, psychologist, dentist, or certified nurse midwife.³

Eligibility begins after four consecutive weeks of work for a covered employer. It resumes immediately if you are returning to the same covered employer from an unpaid leave or vacation, or if you were collecting unemployment insurance before starting a new covered job.⁴ Self-employed individuals without employees are not required to carry the coverage, and domestic workers who work fewer than 20 hours per week in a private household and don’t live on the premises are excluded.⁵

Download the DB-450 from the Workers’ Compensation Board’s claimant forms page at wcb.ny.gov as a fillable PDF.⁶ Your employer or their carrier may also hand you a copy. Do not submit the form before your first day of disability; the instructions on the form say so explicitly.¹

Part A — Your Information

Part A is yours. Enter your full legal name, mailing address, and Social Security number. The form asks for every employer you worked for during the eight weeks immediately before the disability began, because your average weekly wage is calculated from all wages earned in that period.¹

State the date the disability began and the last day you worked. The form also asks whether your condition is related to a motor vehicle accident or any third-party legal action, and whether you are receiving unemployment insurance or other income. Answer honestly. Mismatches between what you report and what the carrier discovers from the employer or other agencies will slow or sink the claim.

Sign and date Part A. Your signature authorizes release of medical information to the carrier, which is required for processing.

Part B — Healthcare Provider’s Statement

Part B is completed by the licensed provider treating you. It asks for the clinical diagnosis, the ICD-10 code, a description of physical limitations or surgical procedures, and the date the provider first treated you for this disability. The provider gives an estimated return-to-work date and includes their license number.¹

This is where most claims stall. Blank fields or vague descriptions in Part B give the carrier an easy reason to send the form back. Before you leave the appointment, check that the disability start date your provider wrote matches what you entered in Part A, and confirm the provider signed, dated, and added their license number.

Part C — Employer Information

Part C is completed by your employer, not by you. When you deliver the form to your employer, they are required to fill out Part C and return it within three business days.¹ They provide the business name, federal employer identification number, your date of hire, the date you last worked, and whether wages were continued during your absence through PTO or sick time.

The employer also calculates your average gross weekly wage from the last eight weeks of earnings before the disability began, including bonuses, tips, and commissions. That number determines your benefit amount. Part C additionally asks whether you have taken any disability or Paid Family Leave in the preceding 52 weeks, which is how the carrier confirms you have remaining weeks of eligibility.

Where To Send the Completed Form

Where the form goes depends on your employment status when the disability began.

If you are currently employed, or unemployed for less than four weeks, submit the form to your employer or your last employer’s insurance carrier. You can look up the carrier using the Employer Coverage Search tool on the Workers’ Compensation Board’s website.¹
If you have been unemployed more than four weeks and are collecting unemployment insurance, mail the completed form to the Workers’ Compensation Board, Disability Benefits Bureau, PO Box 9029, Endicott, NY 13761-9029. The WCB Special Fund for Disability pays the benefit, and the seven-day waiting period does not apply.³

Certified mail with return receipt gives you proof of the delivery date if a deadline dispute arises later. Some carriers accept electronic submissions, so check. Keep a full copy of the signed form regardless of how you send it.

The 30-Day Deadline and Late Filing

Submit the completed DB-450 within 30 calendar days of your first day of disability. Filing late does not automatically kill the claim, but it costs you money: the carrier is not required to pay benefits for any period more than two weeks before the date you actually furnish proof. If you can show it was not reasonably possible to file on time, the Workers’ Compensation Board chair may excuse the delay, and you carry the burden of proving that.⁷

There is a hard outer limit. No benefits will be paid unless proof of disability is furnished during the period of actual disability, up to the 26-week statutory maximum. If you wait until after you have recovered and returned to work, you may have forfeited the claim entirely.

What Happens After You File

Once the carrier receives a complete claim, it reviews the medical evidence and wage information. If the carrier decides to reject the claim in whole or in part, it must issue a Notice of Total or Partial Rejection of Claim for Disability Benefits (Form DB-451) within 45 days of receiving the claim and send you a copy explaining the specific reasons.⁸

If you have received fewer than 26 weeks of benefits, are still disabled, and have not received a rejection notice, submit additional medical evidence to the carrier to request continued benefits.³ Carriers sometimes stop paying without formally rejecting, and updated documentation from your provider is how you keep the benefits flowing.

How To Appeal a Denial

If your claim is denied, you can request a hearing before the Workers’ Compensation Board. An appeal of a judge’s decision must be filed within 30 days of the decision’s filing date, using the Application for Board Review (Form RB-89). If you have an attorney, the appeal must be filed on Form RB-89. The opposing party then has 30 days to file a rebuttal on Form RB-89.1.⁹

The application needs to identify the WCB case number, the insurer’s name, the date of the decision you are appealing, and the specific issues you want reviewed. You may also apply for a rehearing or reopening if new medical evidence becomes available or your condition has changed materially since the original decision.

How Much You Receive and for How Long

The weekly benefit is 50 percent of your average weekly wage, capped at $170 per week in 2026.¹⁰¹¹ For most full-time workers, the actual benefit hits the ceiling. If your average weekly wage is below $20, you receive your full average wage instead.

Benefits are paid for a maximum of 26 weeks of disability during any 52 consecutive-week period, and your combined disability leave and Paid Family Leave in that same window cannot exceed 26 weeks total.³ A seven-day waiting period applies: no benefits are paid for the first seven consecutive days, and payments begin on the eighth day.¹² If you work at more than one covered job, the benefit is calculated using combined wages from all covered employers, still subject to the $170 cap.¹⁰

Pregnancy

Pregnancy qualifies for benefits under the same DB-450. You are eligible starting four weeks before your due date and continuing six weeks after a vaginal delivery or eight weeks after a cesarean section. If complications keep you out longer, benefits can extend up to the full 26-week maximum with supporting documentation from your physician or certified nurse midwife.³ Disability benefits for childbirth are available only to the birth parent, and you cannot collect disability benefits and Paid Family Leave at the same time.

The Form Doesn’t Protect Your Job

The DB-450 replaces part of your wages. It does not, by itself, guarantee your job will be waiting when you recover. Job protection comes from other laws: the federal Family and Medical Leave Act if your employer has 50 or more employees and you have worked at least 12 months, and potentially the Americans with Disabilities Act as a reasonable accommodation. FMLA leave and state disability benefits can run at the same time. If you are approaching the end of your benefits and still cannot return to work, requesting an accommodation in writing creates a record.

1
New York State Workers’ Compensation Board. New York State Notice and Proof of Claim for Disability Benefits
2
New York State Insurance Fund. Filing a Claim
3
New York State Workers’ Compensation Board. Introduction to the Disability Benefits Law
4
New York State Senate. New York State Workers’ Compensation Code 203 – Employees Eligible for Benefits
5
New York State Insurance Fund. Special Circumstances
6
New York State Workers’ Compensation Board. Employees Disability Benefits Forms
7
New York State Senate. New York State Workers’ Compensation Code 217 – Notice and Proof of Claim
8
New York State Workers’ Compensation Board. Disability Benefits Forms for Insurers and Self-Insured Employers
9
New York State Workers’ Compensation Board. Appeals
10
New York State Senate. New York State Workers’ Compensation Code 204 – Disability and Family Leave During Employment
11
New York State Insurance Fund. NYSIF Lowers Standard Disability Benefits Premium Rate 2026
12
New York State Workers’ Compensation Board. What Are Disability Benefits