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NY \| DBL (Statutory Disability Insurance)
Application Forms
DBL - Application - Voluntary Coverage contributory (DB-136) DBL - Application - Voluntary Coverage non-contributory (DB-135) DBL/PFL Application PFL - Application - Voluntary Coverage contributory (PFL-136) PFL - Application - Voluntary Coverage non-contributory (PFL-135) PFL - Employee opt-out (PFL-Waiver)
Claim Forms
Accidental Death & Dismemberment Claim Form COVID-19 Care for minor dependent subject to official "Order of Quarantine" COVID-19 Care for minor dependent subject to official "Order of Quarantine"_Spanish COVID-19 Employees with official "Order of Quarantine" COVID-19 Employees with official Order of Quarantine_Spanish DBL In-Hospital Claim Form (IH-007) Disability Benefit Claim Form (DB-450) Disability Benefit Claim Form (DB-450) - Spanish NY DBL/PFL Direct Deposit Enrollment & Authorization Form NY DBL/PFL Direct Deposit Enrollment & Authorization Form - spanish NYS-issued self attestation: Affirmation of Quarantine NYS-issued self-attestation: Affirmation of Isolation PFL - Claim Form - Bonding PFL - Claim Form - Bonding_Spanish PFL - Claim Form - Military Exigency PFL - Claim Form - Military Exigency_Spanish PFL - Claim Form - Providing Care PFL - Claim Form - Providing Care_Spanish Supplementary Claim Form (APS-NY)
Supplemental Forms
Officer(s) Exclusion Form (DB-212.3) Return-to-Work Notice (W-11) Spousal Exclusion Form (DB212.5) Statement of Rights (DB-271S) Statement of Rights (DB-271S) - Spanish Statement of Rights (PFL-271S) Statement of Rights (PFL-271S) - Spanish Supplement to Certificate of Insurance (DB-820.1)

NY | DBL (Statutory Disability Insurance)

Application Forms

DBL - Application - Voluntary Coverage contributory (DB-136)

DBL - Application - Voluntary Coverage non-contributory (DB-135)

DBL/PFL Application

PFL - Application - Voluntary Coverage contributory (PFL-136)

PFL - Application - Voluntary Coverage non-contributory (PFL-135)

PFL - Employee opt-out (PFL-Waiver)

Claim Forms

Accidental Death & Dismemberment Claim Form

COVID-19 Care for minor dependent subject to official "Order of Quarantine"

COVID-19 Care for minor dependent subject to official "Order of Quarantine"_Spanish

COVID-19 Employees with official "Order of Quarantine"

COVID-19 Employees with official Order of Quarantine_Spanish

DBL In-Hospital Claim Form (IH-007)

Disability Benefit Claim Form (DB-450)

Disability Benefit Claim Form (DB-450) - Spanish

NY DBL/PFL Direct Deposit Enrollment & Authorization Form

NY DBL/PFL Direct Deposit Enrollment & Authorization Form - spanish

NYS-issued self attestation: Affirmation of Quarantine

NYS-issued self-attestation: Affirmation of Isolation

PFL - Claim Form - Bonding

PFL - Claim Form - Bonding_Spanish

PFL - Claim Form - Military Exigency

PFL - Claim Form - Military Exigency_Spanish

PFL - Claim Form - Providing Care

PFL - Claim Form - Providing Care_Spanish

Supplementary Claim Form (APS-NY)

Supplemental Forms

Officer(s) Exclusion Form (DB-212.3)

Return-to-Work Notice (W-11)

Spousal Exclusion Form (DB212.5)

Statement of Rights (DB-271S)

Statement of Rights (DB-271S) - Spanish

Statement of Rights (PFL-271S)

Statement of Rights (PFL-271S) - Spanish

Supplement to Certificate of Insurance (DB-820.1)

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