Disability Insurance Help Center

PLEASE NOTE: The following forms are subject to strict regulatory oversight and may be revised without notice. Please visit this site to retrieve current versions of claim forms for each claim submitted. Please do not save or print large quantities of forms downloaded from this site for future use. Outdated claim forms may be returned with instructions to complete the most current version approved by the state insurance department.

Disability Benefits (NY DBL)

To apply for New York State disability benefits, submit the below claim form. Do not submit this form before your first date of disability. You must submit your completed claim form within 30 calendar days after your first day of disability to avoid losing benefits. This form has a section to be filled out by your health care provider (Part B), and a section to be completed by your employer (Part C). Before providing the form to your health care provider and employer, fill out your section and make a copy to keep. The health care provider is required to return the form to you with Part B completed within seven days. If there is a delay in the health care provider completing Part B, you must wait to submit the form to Renaissance. If Part B is not complete (or has incomplete answers) there may be delay in the payment of benefits. Your employer is required to return the form to you with Part C completed within three business days. If there is a delay in obtaining Part C from your employer and both Part A and Part B are complete, you do not have to wait to proceed, you should send the form to Renaissance. Keep a copy of all forms and documents for your records.

• DBL-450 New York DBL Notice and Proof of Claim 

Paid Family Leave Benefits (NY PFL)

To apply for New York Paid Family leave select the appropriate claim forms packet based on your reason for taking leave.

• New York PFL Bonding PFL-1 and PFL-2 
• PFL-1 and PFL-3 New York PFL For Family Member
• New York PFL Military PFL-1 and PFL-5

Additional Forms:

• New York DBL-PFL Benefits Time-off Verification [PFL-006A-NY]: Have your employer submit this form if you are receiving PTO, vacation pay, or other pay from your employer.
• Intermittent Paid Family Leave Schedule [PFL-001A]: Have your employer submit this form if you are taking intermittent time off under PFL. This form must be submitted after an absence has occurred.
• IRS Form W-4S Request for Optional Federal Income Tax Withholding: Complete this form if you want optional federal income tax withheld from taxable benefit payments.

Additional Information:

• http://www.wcb.ny.gov/content/main/DisabilityBenefits/employee-disability-benefits.jsp
• https://paidfamilyleave.ny.gov/