Product Forms

Statutory Disability Insurance

Product Forms

New York DBL Claims
The forms required when an employee becomes disabled in NY and may be entitled to disability benefits are:

DB-271S—Statement of Rights: The NY DBL law requires an employer to send a “Statement of Rights”
Entitlement of benefits under the Disability Benefits Law to an employee, within 5 days after the employee has been absent from work for more than 7 consecutive days. This statement is in standardized format approved by the Worker’s Compensation Board.

DB-450—Notice and Proof of Claim: After the disability begins, Part A – Claimant and Part B – Health Care Provider statements should be completed, signed and the form returned to the employer for completion of Part C – Employer Statement. The form should then be submitted to Wesco Insurance Company. Claims should be filed within 30 days after the employee last worked and the physician has certified the employee is totally disabled. Failure to submit the claim within 30 days may result in a partial or total rejection of the claim.

 
New Jersey TDB Claims
The forms required when an employee in NJ becomes disabled and may be entitled to disability benefits is:

DS-I – Division of Temporary Disability Insurance Claim for Disability Benefits:
Claim form is used to file a New Jersey TDB claim when an employee becomes totally disabled while employed. Claim must be filed within 30 days of disability. The employer must send the employee a Disability Form (Form DS-1), containing the worker’s name, address, Social Security number and wage information needed to determine the worker’s eligibility for temporary disability benefits.

 
Filing a New York Disability or Paid Family Leave Claim:
Telephonic claims available to all policyholders and employees.
Start a claim with a brief phone call or use any of the following options to file.
 
PHONE: (800) 401-2691
EMAIL:  AmTrustNYDBLPFL@absencesolved.com
FAX: (800) 728-7028
MAIL:
Wesco Insurance Company
C/O AbSolve
P. O. Box 1328
Mt. Laurel, NJ 08054
 
New York DBL Claims - Paid Family Leave
The forms required when an employee in NY may be entitled to Paid Family Leave benefits are:
  • PFL-1 required for all leave types (included in all form packets below) . Part A is for employees to complete. Part B is for Employers to complete.
  • PFL-2 required for Bonding leave
  • PFL-3 & 4 required for Caring for a Family Member leave
  • PFL-5 required for Military Exigencies
Filing a New Jersey Disability Claim
Telephonic claims available to all policyholders and employees.
Start a claim with a brief phone call or use any of the following options to file.
 
PHONE: (800) 401-2691
EMAIL:  AmTrustNJTDB@absencesolved.com
FAX: (800) 728-7028
MAIL:
Wesco Insurance Company
C/O AbSolve
P. O. Box 1328
Mt. Laurel, NJ 08054
 
For additional assistance, please contact one of the service areas below:
Disability Notice to Employer
Request for DB-120.1 Certificate of Insurance Coverage under the NYS Disability Benefits Law
State Disability FAQ
FICA Withholding Worksheet
Application for Coverage - NY
Confidential Communication Request Form for Victims of Domestic Violence and Endangered Individuals
Notice and Proof of Disability Benefits Law Claim - DB450 - NY
Statement of Rights - NY
Request for Updated Medical Information
Return to Work Notification Form - NY and NJ
How to Fill Out an Annual or Quarterly Invoice
Employer's Application for Voluntary Coverage for Whom Disability Benefits are Not Required by Law – Employee Contribution Not Required
Employer's Application for Voluntary Coverage for Whom Disability Benefits are Not Required by Law – Employee Contribution Required
Notice of Election to Voluntarily Exclude Spouse from Coverage

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