Tacoma Employees' Retirement System (TERS) / Office: (253) 502-8200
Fax: (253) 502-8660
3628 S. 35th St., Tacoma, WA 98409 ▪ P.O. Box 11007, Tacoma, WA 98411-0007
Application For DisabilityRetirement Evaluation
Applicant Information Member/Retiree No.______/______
First Name / Middle Initial / Last Name / Social Security Number
Mailing Address / City / State / Zip Code
Telephone Number (daytime) / Telephone Number (evening) / Date of Birth
Marital Status
Single Married / Title of Position / Department
(Office Use Only)Date of Separation:
PER\BEN\DISABILITY\Application for Disability Evaluation(6-2011)
I certify that my disability is not due to willful misconduct or violation of law. Only check one box.My incapacity for the performance of my duties was caused directly by an accident or fortuitous event caused by or incurred as
a result of the actual performance of duties as an employee of the City of Tacoma. I authorize the Retirement Office to obtain
copies of the related records from the City’sWorkers Compensation files.______
(signature required)
My disability is caused by the following medical condition(s). If more than one condition exists, specify each of them.
Explain when you became disabled and how your medical condition(s) affect your ability to work. Attach additional page
if necessary.
______
______
You must provide the Retirement Office records of your medical history and have your physician(s) submit a statement(s) as to any limitations in your ability to work and descriptions of any treatment and/or rehabilitation plans.
Tacoma Municipal Code (1.30.630) Disability Retirement – Authorization
Any member while in City Service or any member on leave of absence or disability leave may be retired by the Board of Administration for permanent and total disability upon examination as follows:
- Any member who becomes incapacitated for the performance of duty because of any accident or fortuitous event caused by or incurred as a result of the performance of duties as an employee of the City of Tacoma, regardless of length of service with the City, may be retired upon disability, as provided in this Section1.30.630. Any member who has not elected to receive a service retirement allowance, and who has at least five years of creditable service (provided, that the required five years of City Service shall have been credited to the member over a period not to exceed ten years immediately preceding retirement), may apply for a disability retirement, a member may apply for a disability retirement within one year of discontinuance of City Service if the member applied for benefits under the City’s Basic LongTerm Disability Insurance Plan within 180 days of discontinuance of City Service for a condition that was present while in City Service and is receiving LongTerm Disability payments. Otherwise a member must apply for a disability retirement within three months after discontinuance of City Service and show that the member’s incapacity has been continuous from discontinuance of City Service.The member shall be examined by a physician or surgeon appointed by the Board of Administration upon application of the head of the office or department in which the member is employed, or upon application of the member or a person acting in his or her behalf. The examining physician or surgeon must find in writing that the member is permanently and totally incapacitated, either physically or mentally, for the performance of duty and ought to be retired. If such medical examination shows to the satisfaction of the Board that the member is permanently and totally incapacitated either physically or mentally, for the performance of duty and ought to be retired, the Board shall retire the member for disability forthwith
Date Signature
PER\BEN\DISABILITY\Application for Disability Evaluation(6-2011)