Request for Workers' Compensation/Public Disability Benefit Information

Claimants for Social Security disability payments who are also receiving WC/PDB must notify SSA about their WC/PDB, so the agency can consider a possible offset to reduce their Social Security disability payments accordingly. If claimants provide necessary evidence, such as a copy of their award notice, benefit check, etc. that is sufficient verification. In cases where claimants cannot provide such evidence, SSA uses Form SSA-1709 to obtain WC/PDB payment evidence. The entity paying the WC/PDB benefits, its agent (such as insurance carrier), or an administrating public agency completes this form. The respondents are Federal, State, and local agencies; insurance carriers; and public or private self-insured companies administering WC/PDB benefits to disability claimants.

The latest form for Request for Workers' Compensation/Public Disability Benefit Information expires 2027-08-31 and is listed under ICR 202104-0960-009.

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