HomeMy WebLinkAboutDisability Leave Application
Application for Disability Leave or Retirement
Name
SSAN
Address
Zip
Sex
Date of Birth
Phone ( )-
Name of Employer
Date Hired
Rank and Position
I hereby apply for disability benefits effective (date) according to the
provisions of R.C.W. 41.26.120 (duty incurred) or R.C.W. 41.26.125 (non-duty incurred). My
last day of service was or will be (date)
The nature of my disability is (describe briefly):
This disability [ ] was, [ ] was not (MUST check one) incurred in the line of duty.
This disability [ ] was, [ ] was not (MUST check one) incurred while in other employment.
This is a [ ] physical, [ ] mental, [ ] physical and mental (MUST check one) disability.
I hereby submit statement(s) by my physician(s) regarding my disability and
authorize my physician(s) to supply you with any information which you may request. I also
consent to examination by your board appointed physician or board approved specialist. I
understand that my consent is given only for the purpose of establishing my right to disability
benefits.
The information contained herein is true and complete to the best of my knowledge and belief.
Applicant Signature
Date
LEOFF Representative Signature
Date
Revised 10/92 (F:\clerk\leoff\ppforms)
Phvsician List
Per WAC 415-105-040(4) and the City of Auburn LEOFF Board Policies and Procedures
3.10, each application shall be accompanied by a list identifying by name any physician
who has been contacted within the last six months for which disability is claimed. This
form is to be comleted by the applicant and submitted with his/her application for
disability leave or retirement. Failure to complete this form and submit it with the
application will result in delay or refusal of the application.
The following list is of any physician who has been contacted within the last six months
for the illness or injury for which disability is claimed.
Name and Address
Name and Address
Name and Address
Name and Address
Name and Address
Name and Address
Name and Address
Family Information
Wife's Given Name, Initial, Birth Date
Date of Marriage, Place of Marriage
Child (Stepchild), Birth Date, Place of Birth
Child (Stepchild), Birth Date, Place of Birth
Child (Stepchild), Birth Date, Place of Birth
Child (Stepchild), Birth Date, Place of Birth
Child (Stepchild), Birth Date, Place of Birth
I hereby certify, under oath, that the above information is true and correct.
Applicant Signature