NY DB-212.5 2006 free printable template
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STATE OF NEW YORK WORKERS COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. NOTICE OF ELECTION TO VOLUNTARILY EXCLUDE SPOUSE FROM COVERAGE PURSUANT
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How to fill out NY DB-212.5
01
Obtain the NY DB-212.5 form from the New York State Workers' Compensation Board website or your employer.
02
Fill out your personal information at the top of the form, including your name, address, and contact details.
03
Enter the date of your injury or incident in the specified section.
04
Provide details about your employer, such as the name of the business and the address.
05
Complete the section describing the specifics of your injury, including how it occurred and any relevant medical information.
06
Include the name and address of any medical providers you have seen for your injury.
07
Sign and date the form at the bottom to validate your submission.
08
Make a copy of the completed form for your records before submitting it according to the instructions provided.
Who needs NY DB-212.5?
01
Employees who have sustained a work-related injury or illness in New York State.
02
Individuals seeking to file a claim or report an injury to their employer or the Workers' Compensation Board.
03
Workers who need to provide documentation for benefits or compensation related to their injury.
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What is NY DB-212.5?
NY DB-212.5 is a form used in New York State for reporting contributions made to a disability benefits fund by employers.
Who is required to file NY DB-212.5?
Employers in New York who provide disability benefits to their employees are required to file NY DB-212.5.
How to fill out NY DB-212.5?
To fill out NY DB-212.5, employers need to provide details about their business, including employee information, the amount of disability benefits provided, and contributions made to the fund.
What is the purpose of NY DB-212.5?
The purpose of NY DB-212.5 is to ensure that employers report their contributions to the disability benefits fund, maintain compliance with state laws, and facilitate the provision of disability benefits to eligible employees.
What information must be reported on NY DB-212.5?
Employers must report information such as the total number of employees, the amount of contributions made to the disability benefits fund, and any claims made by employees for disability benefits.
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