Form DB-450 New York Disability Benefits: Filing Deadline and Steps

To file for New York disability benefits, you fill out Form DB-450 in two parts: Part A is your own statement about the disability, your wages, and your work history, and Part B is a medical certification signed by your treating healthcare provider. Both parts have to be complete before you send the form to your employer’s disability insurance carrier (or, in some situations, directly to the Workers’ Compensation Board), and you have 30 calendar days from your first day of disability to file.¹

One thing to confirm before you start: DB-450 covers only non-work-related illness or injury. If you got hurt on the job or you have an occupational disease, that’s a workers’ compensation claim, not this form.

Getting the Form

Download the DB-450 as a fillable PDF from the Workers’ Compensation Board’s website. You can also ask your employer or their insurance carrier for a copy. If you don’t know which carrier holds your employer’s disability policy, look it up using the Employer Coverage Search tool at wcb.ny.gov.¹

Completing Part A: Your Statement

Part A is yours to fill in. Gather your information before you start, because blank fields and wrong dates are the most common reason claims stall.

Fields 1 through 6 are basic identifying information: full name, mailing address, daytime phone, email, Social Security number, date of birth, and gender.

Field 7 asks for a description of your disability. Write what’s wrong. If it’s an injury, explain how, when, and where it happened. Specific beats vague. “Lower back pain after a fall at home on March 3” is more useful than “back injury.”

Field 8 covers your disability dates and work status: the exact date you became disabled, whether you worked that day, whether you have recovered, and whether you have done any work for pay since the disability started.

Field 9 is your employer information. Enter the name, address, and phone number of your last employer before the disability. If you worked for more than one employer in the eight weeks before the disability, list them all. Your average weekly wage is calculated from wages earned during those eight weeks, and the form has a week-by-week table where you enter days worked and gross pay for each of the last eight weeks.

Fields 10 and 11 ask for your job title and, if you belong to one, your union name or local number.

Field 12 asks about unemployment. Say whether you were claiming or receiving unemployment benefits before the disability began. If you were not collecting unemployment after your last day worked, explain why.

Field 13 asks about other benefits: wages, separation pay, unemployment, Paid Family Leave, workers’ compensation, no-fault auto accident benefits, or Social Security disability. Checking “yes” to any of these doesn’t automatically disqualify you. Failing to disclose them can.

Fields 14 and 15 ask whether you received disability benefits or Paid Family Leave during the 52 weeks before this disability began. This matters because disability and PFL share a combined 26-week cap within any 52-week period.

Field 16 asks whether your employer gave you information about your disability rights within five days of your request.

Sign and date Part A. An unsigned form will be rejected outright.¹

Completing Part B: Your Health Care Provider’s Statement

Part B has to be completed and signed by your treating healthcare provider. The form limits who can sign it to a physician, chiropractor, dentist, podiatrist, psychologist, or certified nurse-midwife.¹ Nurse practitioners are not on that list, so check before you schedule an appointment specifically for this paperwork.

Your provider documents the diagnosis, the dates of treatment, and the first day you were unable to work, and gives an estimated return-to-work date. The form instructs the provider to complete and return it within seven days of receiving it. Don’t just hand it off and forget about it. Follow up. Incomplete medical sections are the second most common cause of claim delays, right behind missing dates in Part A.

Where to Send the Completed Form

Where the DB-450 goes depends on your employment status when the disability started.

If you are currently employed, or you became disabled within four weeks of leaving a job, send the form to your employer or your employer’s disability insurance carrier.¹

If you became disabled more than four weeks after your last day of employment, mail the form directly to the Workers’ Compensation Board at Disability Benefits Bureau, PO Box 9029, Endicott, NY 13761-9029. If you were collecting unemployment when the disability began, the New York State Special Fund for Disability Benefits pays the claim, but you still mail the form to that same Endicott address.²

If your disability involves a no-fault motor vehicle accident or an injury caused by someone else’s negligence, complete and submit Form DB-450.1 (Claimant’s Statement Regarding No Fault or Personal Injury) alongside the DB-450.²

The 30-Day Filing Deadline

You must submit the completed DB-450 within 30 calendar days of your first day of disability.¹ Miss that window and you risk losing benefits entirely or having payment reduced for the period before you filed. The form warns you to submit “promptly to avoid delaying your claim,” and that language understates the consequences. A late filing can mean lost money you cannot recover.

If your provider is slow to return Part B, don’t wait for perfection. Get the form in within 30 days, even if it means hand-delivering it and following up with the provider’s office afterward.

What Happens After You File

Once the insurance carrier receives your completed DB-450, it must either pay the claim or issue a formal denial within 18 days. Carriers that miss this deadline face penalties from the Workers’ Compensation Board.³

No benefits are paid for the first seven consecutive days of disability. Payments begin on the eighth day.⁴ This waiting period catches people off guard, so plan for a full week without payment before the first check arrives. In practice, expect two to three weeks between filing and receiving your first check if everything goes smoothly.

Payments equal 50 percent of your average weekly wage over the eight weeks before your disability began, up to a maximum of $170 per week.⁵ That $170 cap has not changed in decades and remains $170 for 2026.⁶ If your average weekly wage is below $20, you receive that full amount instead. Benefits last up to 26 weeks in any 52-consecutive-week period,⁷ and any Paid Family Leave you used during that 52 weeks counts against the same 26-week pool.²

If Your Claim Is Denied

The carrier must tell you in writing why the claim was rejected. Common reasons include incomplete medical documentation, a disability that appears work-related (which belongs in workers’ compensation), or filing past the 30-day deadline.

You can request a hearing before a Workers’ Compensation Board judge. If the judge rules against you, appeal to a Board panel by filing an Application for Board Review (Form RB-89) within 30 days of the judge’s decision. The opposing party then has 30 days to file a rebuttal on Form RB-89.1. Legal briefs are limited to eight pages; longer briefs require a written justification and cannot exceed 15 pages under any circumstances.⁸

1
New York State Workers’ Compensation Board. DB-450 Notice and Proof of Claim for Disability Benefits
2
New York State Workers’ Compensation Board. Workers Disability Benefits
3
New York State Workers’ Compensation Board. Subject Number 046-936 2017 Workers Compensation Reform
4
New York State Workers’ Compensation Board. What Are Disability Benefits
5
New York State Senate. New York Workers Compensation Law WKC 204
6
New York State Insurance Fund. NYSIF Lowers Standard Disability Benefits Premium Rate 2026
7
New York State Senate. New York Workers Compensation Law WKC 205
8
New York State Workers’ Compensation Board. Appeals