62-5 SPD:62/5 SPD.qxd - NYCERS

SUMMARY PLAN DESCRIPTION - 62/5 TIER 4 MEMBERS VERSION APRIL 2012FOR EXAMPLE:A disabling injury sustained by a member while in the performance of duty due to an incidentwhich involves routine lifting or bending would not qualify as an accident.FILING AN APPLICATION FOR DISABILITY RETIREMENTYou must file an application for a Disability Retirement Benefit:1. within three months from the last date you were being paid on the payroll, OR2. while you are on a leave of absence without pay for medical reasons, either voluntarily orinvoluntarily, OR3. no later than 12 months after the date you receive notice that your employment has beenterminated, provided that you were on an approved leave of absence without pay for medicalreasons, which was in effect immediately prior to such termination.LR: Chapter 414 of the Laws of 1983SR: RSSL §605 subdivision b(2)The application must be filed:by you, ORby a person with legal authority to act on your behalf, ORby the head of the agency where you are employedLR: Chapter 414 of the Laws of 1983SR: RSSL §605 subdivisions a(1) and a(2)NOTE: See the Special Disability Provisions subsection on pages 54 and 55 for filing requirementsif you are an Emergency Medical Technician (EMT) or Deputy Sheriff applying for a threequartersdisability benefit.DISABILITY APPLICANTS NEED THE FOLLOWING:Form # 801 - Instructions for Members Applying for Disability RetirementForm # 604 - Application for Disability Retirement for Tier 4 MembersForm # 605 - Applicant's Report of Personal DisabilityForm # 606 - Physician's Report of DisabilityForm # 608 - General Authorization for Release of Medical InformationForm # 609 - Questionnaire to be Completed by Applicant for Disability RetirementDue to medical privacy laws, you must authorize NYCERS to request information from your treatingphysician/medical facility. Please be advised that upon authorization, it is NYCERS’ practiceto contact public hospitals and/or H.I.P. Centers. If you have a private physician or your medicalprovider practices in another healthcare facility, it is your responsibility to submit any and allmedical evidence to support your claim for disability.If you are claiming that your disability was the result of an on-the-job accident, NYCERS will sendan Agency Report on Accident to your agency to verify the accident/incident. When your agencyreturns the Agency Report on Accident, it will also submit documentation such as an incidentreport prepared by you, your manager or supervisor, or a witness, which describes all of theinjuries and the events surrounding them. This report is most valuable if it is written at the timeof the accident/incident.WWW.NYCERS.ORGDISABILITY RETIREMENT47