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NEW YORK DISABILITY BENEFITS LAW (DBL) FORMS

Click here for NJ TDB Forms

  Form Id   Form Name   Description Word PDF
DB-120.1 REQ Request for DB-120.1 Certificate of Insurance Coverage under the NYS Disability Benefits Law Used to request a DB-120.1 the certificate of insurance that provides proof of NYS DBL coverage. Request may be submitted to NBL by Fax or Email.

 

General Information About DBL

  Form Id   Form Name   Description Word PDF
DBK The DBL Book Employer's question and answer guide to the Disability Benefits Law (DBL). N/A
SPAC Statutory Plans Around the Country Chart which outlines the states that have mandated off-the-job disability benefits for workers and their coverages. N/A
OC-923 Important Information for Employers Operating in New York State. General Workers' Compensation and Disability Information for employers in New York State. N/A

 

Rates and Application for NY DBL Coverage

  Form Id   Form Name   Description Word PDF
42-R 6.08 DBL Rate Card Rates for employer groups with fewer than 50 employees. N/A
DBL QQ1 DBL Quick Quote Request To request a NY DBL quote for employer groups with 50 or more employees. N/A
A8-906-DBL Application for NY Disability Benefits Law
Coverage		 To apply for NYS Disability Benefits Law (DBL) coverage with National Benefit Life. No deposit premium is required. Should be submitted by employer's agent or broker.

 

DBL Policy Administration

  Form Id   Form Name   Description Word PDF
F1-B How to Calculate taxable FICA percent Worksheet to determine percentage of benefit subject to tax.
PCR Policy Change Request To notify NBL of a name or address change, new entity or cancellation of an employer. N/A
DB-120.1 REQ Request for DB-120.1 Certificate of Insurance Coverage under the NYS Disability Benefits Law Used to request a DB-120.1 the certificate of insurance that provides proof of NYS DBL coverage. Request may be submitted to NBL by Fax or Email.
 DB-135 Employer's Application for Voluntary Coverage for Whom Disability Benefits are Not Required by Law (Employee Contribution Not Required) To voluntarily cover a class or classes of employees for whom Disability Benefits is not required under the Law and no employee contribution will be withheld. N/A
DB-136 Employer's Application for Voluntary Coverage for Whom Disability Benefits are Not Required by Law (Employee Contribution Required) To voluntarily cover a class or classes of employees for whom Disability Benefits is not required under the Law and the statutory employee contribution will be withheld. N/A
DB-212.5 Notice of Election to Voluntarily Exclude Spouse from Coverage To voluntarily exclude spouse from DB coverage. N/A

 

DBL Claims

  Form Id   Form Name   Description Word PDF
DB-450 Notice and Proof of Disability Benefits Law Claim Claim form used to file a NY DBL claim when an employee becomes disabled while employed or within 4 weeks after termination. Must be filed with NBL within 30 days of disability. N/A
DB-271S Statement of Rights (DBL) Employer must send to employee, along with a DB-450 Claim form within 5 business days after a covered employee is absent from work due to disability for more than 7 consecutive days. N/A
DB14A Request for Updated Medical Information Supplemental Medical Form - to be completed by claimant and their attending physician. N/A
NTE DBL Notice to Employer Sent to employer requesting information on a DBL claimant. The form must be completed and returned to NBL. N/A