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Get 271s form 2017-2024

Your employer s disability benefits insurance carrier is KENNETH J. MUNNELLY CHAIR NYS Workers Compensation Board Centralized Mailing PO Box 5205 Binghamton NY 13902-5205 Customer Service Toll-Free Line 877-632-4996 DB-271S 9-16 THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. ESTE RESUMEN ESTA ESCRITO EN ESPANOL AL DORSO. WORKERS COMPENSATION BOARD Kenneth J* Munnelly Chair STATE OF NEW YORK Andrew M. Cuomo Governor STATEMENT OF RIGHTS - DISABILITY BENEFITS LAW IF YOU ARE UNABLE TO WORK BECAUSE OF A NON-OCCUPATIONAL ILLNESS OR INJURY YOU MAY BE ENTITLED TO DISABILITY BENEFITS 1. Your employer is required by law to provide for the payment of Disability Benefits to his/her employees. 2. Statutory Disability Benefits are payable for any non-work related injury or illness including disability due to pregnancy beginning with the 8th consecutive day of disability. Benefits are payable for up to 26 weeks. Benefit payments are based on your average weekly wages for the eight weeks immediately prior to your disability and are subject to the maximum allowable by the law in effect on the initial day of disability. Your employer or union may provide for different benefits which are at least as favorable as statutory benefits under an approved Disability Benefits Plan or Agreement. 3. TO CLAIM BENEFITS you should file written notice and proof of disability Claim Form DB-450 with your employer or the insurance carrier named below within 30 days from the first day of your disability or all or part of your claim may be rejected* In no event should you wait more than 26 weeks from that date to file a claim* You may obtain Form DB-450 from your employer its insurance carrier your health care provider or by contacting the Workers Compensation Board. See address and telephone number below. Do not assume that your employer has filed a claim on your behalf claim filing is your responsibility. 4. You are entitled to be treated by any physician chiropractor dentist nurse-midwife podiatrist or psychologist of your choice. Unlike workers compensation your medical bills will not be paid by your employer or the insurance carrier unless your employer and/or union provides for the payment of medical bills under an approved Disability 5. Disability Benefits are to be paid directly to you by the insurance carrier not through your employer unless your employer is an approved self-insurer. 6. If your employer or the insurance carrier contends that you are not entitled to the payment of Disability Benefits they are required to send you a Notice of Rejection within 45 days of the filing of your claim telling you the reasons benefits are not being paid* If you disagree with their rejection you have a legal right to request a review of the rejection by the Workers Compensation Board. IMPORTANT If within 45 days of filing your claim you do not receive benefits and do not receive a Notice of Rejection Form DB-451 promptly contact the Workers Compensation Board at the telephone number below.

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