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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