Request for Workers' Compensation/Public Disability Benefit Information

SSA uses Form SSA-1709 to verify Worker's Compensation/Public Disability Benefits (WC/PDB). SSA uses the information to compute the correct reduction of disability insurance benefits. The claimants may be able to furnish adequate verification of the WC/PDB benefits by submitting a copy of their award notice, benefit check, etc. SSA considers the claimants the primary sources of verification; therefore, if they provide the necessary evidence, we do not use the form. If the claimants cannot provide evidence, the other reliable source of this information is the entity giving the benefits, its agent (such as an insurance carrier), or an administering public agency. The respondents are Federal, State, and local agencies, insurance carriers and public or private self-insured companies administering WC/PDB.

The latest form for Request for Workers' Compensation/Public Disability Benefit Information expires 2021-10-31 and can be found here.