Claim for Disability Benefits - Form DS-1
To enable the disabled worker to file for temporary disability benefits (Part A).
To secure a medical certification from the attending physician to support the claim (Part B).
To notify the employer that the worker is claiming temporary disability benefits.
To secure the employer wage and separation information needed to determine the claimant's eligibility (Part C). (See Form)
NOTE: The claimant is instructed to have the employer complete Part C (Employer's Statement) of Form DS-1 while he/she waits, but if this cannot be done, to mail it to the Division immediately. This should be done to satisfy the section of the law that requires the claimant to file his/her claim within 30 days of the beginning of the disability.