Questionnaire for NYS Short-Term Disability (DBL) * See If You Qualify *

Questionnaire for NYS Short-Term Disability (DBL)
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Non-Profit Organization?
Full Time or Part Time Employee?
Job Title?
Date of hire?

MonthDayYear
Date
Type of injury or medical condition?
Did injury occur at work?
Employed in New York State?
High School Student?
Last day worked before disability? Leave blank if currently working.

MonthDayYear
Date
By submitting this form you confirm the information provided is true and correct to the best of your knowledge and can be relied upon in determining qualification for New York Short-Term Disability.
Should be Empty: