Disability Claims Reporting
About Disability and Paid Family Leave Claims Reporting
Download and complete the necessary form(s) from the list below:
Disability Claim Forms:
If one of your covered employees becomes ill or injured away from the job, you’ll need to download and submit within 30 days of the start of the disability: Notice and Proof of Claim for Disability Benefits (Form NY DBL - DB 99 10 08 07 11) accompanied by the Statement of Rights (Form DB-271S).
Additional disability claims forms:
For Paid Family Leave Claims:
Form PFL-1 as well as PFL-2, PFL-4, and/or PFL-5 along with supporting documentation must be submitted at least 30 days prior to the start of your leave (when known). For your convenience, we have grouped the required forms based on the reason for the leave: PFL-Bonding_with_New_Child, PFL-Care_for_Family_Member, or PFL-Military.
In all cases, the employer and employee each have portions of the documents that need to be filled out with medical practitioners sometimes being required as well.
The completed form(s) can be sent to us via e-mail at firstname.lastname@example.org; fax at 570-825-0611; or mail at:
P.O. Box 1368
Wilkes-Barre, PA 18703-1368
Be sure to sign and date the document(s) before returning to us.