Db681 2026

The document is a Self-Insurer Annual Report for employers in New York, detailing requirements for reporting Disability and Paid Family Leave benefits. It includes sections for employer information, employee coverage data, corporate structure updates, claims administration details, and contact information. The report must be completed by an authorized official and notarized before submission to the state. Instructions clarify eligibility criteria for employees and emphasize the need for accurate reporting of payroll and employee numbers.

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Click ‘Get Form’ to open the db681 in the editor.
Begin by entering your Employer name and address at the top of the form. Ensure you include your full legal name, including designations like 'Inc.' or 'LLC'.
In the first chart, input the number of eligible New York employees covered by self-insurance and their corresponding payroll amounts for both Disability Benefits and Paid Family Leave Benefits.
For Corporate Structure/Ownership Update, indicate if there have been any changes since your last report by checking 'Yes' or 'No'. If applicable, attach necessary documents.
Fill in the primary contact information for Disability Benefits and Paid Family Leave, ensuring all fields are completed accurately.
Complete the Claims Administration section by selecting whether you self-administer or use a licensed claims administrator for benefits.
Finally, ensure that an Authorized Official signs the report and that it is notarized before submission.

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