NY DB-135 2017 free printable template
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EMPLOYER\'S APPLICATION FOR VOLUNTARY COVERAGE for Class of Employees for Whom Disability Benefits are Not Required by Law
(No Employee Contribution)
Bureau of Compliance, 328 State Street, Schenectady,
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How to fill out NY DB-135
01
Obtain the NY DB-135 form from the New York State Workers' Compensation Board website or your employer.
02
Fill in the 'Employee Information' section with your personal details such as name, address, and Social Security number.
03
Complete the 'Employer Information' section with your employer's name, address, and workers' compensation insurance information.
04
If applicable, provide details about the injury or illness, including the date it occurred and how it happened.
05
Sign and date the form to certify that the information provided is accurate.
06
Submit the completed form to your employer, who will then forward it to the insurance carrier.
Who needs NY DB-135?
01
Employees who have suffered a work-related injury or illness and need to file for workers' compensation benefits.
02
Employers who must submit the form to their workers' compensation insurer.
03
Insurance carriers that require the form for processing claims related to workplace injuries.
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What is NY DB-135?
NY DB-135 is a form used in New York State for reporting specific employee information related to disability benefits.
Who is required to file NY DB-135?
Employers who provide disability benefits to their employees or participate in the New York State Disability Benefits Law are required to file NY DB-135.
How to fill out NY DB-135?
To fill out NY DB-135, employers need to provide details such as the employee's personal information, the nature of the disability, and the relevant dates associated with the disability claim.
What is the purpose of NY DB-135?
The purpose of NY DB-135 is to report and document employee claims for disability benefits under the New York State Disability Benefits Law.
What information must be reported on NY DB-135?
NY DB-135 requires reporting of the employee's name, address, Social Security number, date of disability, type of disability, and employer information.
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