Imrf Form 5 40 PDF Details

When an employee of the Illinois Municipal Retirement Fund (IMRF) faces a condition that incapacitates them from working for more than 30 days, navigating the process for applying for disability benefits is critical. Key to this process is the IMRF Form 5.40, a comprehensive document designed to facilitate the application for disability benefits. Revised in June 2012, this form serves as the initial step, guiding the applicant through a sequential procedure starting from the cessation of work due to disability through to the submission of the application directly to the IMRF. Applicants are instructed to not only send in their application, which includes detailed personal information but also coordinate with their employer and physician(s) to file necessary supplementary forms. Specifically, the employer is responsible for submitting an Employer's Statement, while the applicant's physician(s) must complete a Physician’s Statement of Disability Claim. Additionally, the form serves as a guide for lodging any worker's compensation claims concurrently, ensuring all bases are covered to facilitate a smooth transition into disability leave. Moreover, the form intricately details the filing and attachment guidelines, emphasizes the importance of providing the applicant's Social Security number on all documents, and outlines the procedure for those returning to work on a part-time basis under the "Trial Work Period." Beyond the immediate application process, the form provides critical information on federal income tax withholding for disability payments, underscoring the necessity for clear and precise completion of the form to prevent any delays in the processing of the claim or receiving the benefits due.

QuestionAnswer
Form NameImrf Form 5 40
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other names1-800-ASK-IMRF, DateofConsultation, 12a, IMRF

Form Preview Example

The first two pages of this form are not enterable. Please print and keep for your records.

Application for IMRF Disability Benefits

IMRF Form 5.40 (Rev. 6/2012)

Please use this checklist when applying for IMRF disability benefits.

As soon as you stop working and you feel you will be disabled more than 30 days. . .

1. File an Application for Disability Benefits (IMRF Form 5.40) with IMRF. We recommend you submit your application directly to IMRF.

•You can also fax your application to IMRF at 630-706-4289.

•File the form even if you filed a worker’s compensation claim.

•Print your Social Security number on all documents you enclose with the form.

MAILED

FAXED

____________________________________________

DATE YOU FILED

2. Call your employer and ask them to file an Employer’s Statement with

IMRF (IMRF Form 5.41). Your employer should have the form. If not, they can download the form from www.imrf.org.

•Write down the name of the person you spoke with and the date.

•Ask when the employer thinks the form will be submitted to IMRF.

____________________________________________

PERSON YOU SPOKE WITH

____________________________________________

DATE

____________________________________________

DATE EMPLOYER WILL SUBMIT

3. Provide your physician(s) (the first physician who examined you for this

disabling condition) with a Physician’s Statement of Disability Claim

(IMRF Form 5.42) and have your physician(s) submit the documentation to IMRF, with copies of your medical records from the date of

disability.

•Write down the name of the person you spoke with and the date.

•Ask when the physician(s) will complete the form and submit it to IMRF.

____________________________________________

PERSON YOU SPOKE WITH

____________________________________________

DATE

____________________________________________

DATE PHYSICIAN WILL SUBMIT

4. IMRF will acknowledge receipt of your claim in writing. Call IMRF at 1-800-ASK-IMRF (1-800-275-4673) if you have not heard anything within 10 business days after the date of your acknowledgement letter. IMRF will request additional medical information, if needed, directly from your medical providers (you will receive a copy of any such request).

5. When IMRF receives any of the above three forms, we will mail you an acknowledgment letter and an IMRF Disability Benefits booklet. We will also request any missing forms.

See the reverse side of this checklist for instructions on how to complete the attached form.

PLEASE NOTE:

•You should contact IMRF if you are considering RESIGNING from your current position. Resigning your position may impact your eligibility for IMRF disability beneits.

•Please be advised that IMRF disability payments are paid at the beginning of the month for the previous month.

Illinois Municipal Retirement Fund

2211 York Road, Suite 500, Oak Brook Illinois 60523-2337

Member Services Representatives PH 1-800-ASK-IMRF (1-800-275-4673) • FX 630-706-4289 • www.imrf.org

IMRF Form 5.40 (Rev. 6/2012)

Who does what in this process?

•You need to print your Social Security number on all documents you send to IMRF (e.g., your birth certificate).

•Your employer needs to file an Employer’s Certificate of

Disability (IMRF Form 5.41).

•Your physician(s) needs to file a Physician’s Statement of

Disability (IMRF Form 5.42). You must provide the physician(s) with the form.

•If your doctor releases you to return to work on a part-time basis, you should refer to “Trial Work Period” in the IMRF

Disability Benefits booklet.

Instructions for completing Questions 1 - 11

Q 1A, 1B, 1C Enter the requested information. If you do not

answer question 1B, you will delay processing of your claim. If appropriate, answer question 1C.

Q 2 Enter the last date you worked. Do not file this claim if you are still working. If you will be disabled due to a planned event (e.g., elective surgery, pregnancy), submit this form after your last day at work. If you do not

answer question 2, you will delay processing of your claim.

Q 3A, 3B, 3C If appropriate, enter the requested information.

Q 4 Answer either yes or no.

Q 5 Answer yes or no and, if appropriate, enter the requested information.

Q 6 Answer either yes or no. And, if appropriate, indicate status of claim—check all that apply.

Q 7 Answer either yes or no.

Q 8 Answer yes or no and, if appropriate, enter the requested information.

Q 9, 9A Answer yes or no and, if appropriate, enter the requested information.

Q 10 Enter the name, address, and phone number of each doctor you saw and the date of each visit.

Q 11 Enter the name, address, phone number, and dates of treatments for each hospital in which you were treated.

Question 12 - W-4P Federal Income Tax Withholding Certificate information

This question serves as a substitute IRS Form W-4P.

IMRF disability benefits are subject to federal income tax.

IMRF must withhold income tax unless you elect on line 12a not to have tax withheld.

If you elect to have income tax withheld, complete line 12b. If you complete line 12b and also want an additional amount withheld from your monthly disability benefit payments, enter this

amount on line 12c.

CAUTION: Remember that there are penalties for not paying enough tax during the year. For more information, please see IRS Publication 505, “Tax Withholding and Estimated Tax,” available from most IRS offices or from www.irs.gov.

•You may use IRS Form W-4P in lieu of Question 12. Form W-4P is available online at www.irs.gov and at most IRS offices.

Purpose

Unless you elect otherwise, federal income tax will be withheld from your disability benefit. The law requires that unless

you tell IMRF otherwise, tax will be withheld on IMRF monthly

payments as if you are married and claiming three withholding

allowances. To view the tax amount to be withheld under current regulations, read “Tax Letter #13,” at www.imrf.org under “Publications.”

You can use this certificate (Question 12) to instruct IMRF to do any of the following:

•To withhold no tax from your disability payments.

•To withhold taxes based on the number of allowances and marital status you indicate.

•To withhold an additional amount you specify from each payment.

Your tax withholding instruction stays in effect until you change or revoke it. IMRF must notify you each year of your right to elect to have no tax withheld or to revoke your election.

Statement of income tax withheld from your disability payments

By January 31 of next year, you will receive a statement (1099-R) from IMRF showing the total amount of your disability payments and the total income tax withheld during the year. Any IMRF disability payments you receive will be subject to federal income tax, but not to Illinois state income tax. If you are a resident of another state, please check with your state’s Department of Revenue to learn whether you will pay that state’s income tax on IMRF disability benefits.

If you are totally and permanently disabled, you may be eligible for a tax credit. For additional information about the tax

credit, you can contact a tax advisor or call 1-800-TAX-FORM

(1-800-829-3676) and request IRS publication 524 “Credit for the Elderly or the Disabled;” this IRS publication may be downloaded at www.irs.gov.

IMRF Form 5.40 (Rev. 6/2012)

MEMBER’S APPLICATION FOR DISABILITY BENEFITS

IMRF Form 5.40 (Rev. 6/2012)

Please Print or Type – Use Black Ink

 

 

 

 

 

 

 

 

 

Member’s Last Name

First

Middle Initial

 

Social Security Number

 

 

 

 

 

 

 

 

 

________________ - ________ - ________________

Street (Mailing) Address

City, State and ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone:

(

)

 

Cell Phone:

(

)

Email:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FILING GUIDELINES

•Do not file this claim if you are still working.

•If you will be disabled due to a planned event (e.g., elective surgery, pregnancy), submit this form after your last day at work.

•You should file this application if you expect to be disabled for more than 30 days.

•File this form even if you plan to file a workers’ compensation and/or occupational disease claim.

ATTACHMENT GUIDELINES

•A copy of your birth certificate should be filed with this application. If that document is delayed, file this application without it.

•Please print your Social Security number on all documents you enclose with this form.

IF YOU RETURN TO WORK ON A PART-TIME BASIS

• Refer to “Trial Work Period” in the IMRF Disability Benefits booklet.

1A.

Nature of illness or injury

3A. Was this injury caused by an accident?

5.

Has your disability ended?

 

_________________________________

 

No

 

 

 

Yes

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

Date ____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of first treatment for this disability (i.e.,

3B. If yes, how and where accident happened:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1B.

Are you applying for workers’ compensation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

date of first doctor visit)

_________________________________

 

and/or occupational disease benefits?

 

_________________________________

 

 

_________________________________

 

 

 

 

No

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

3C. Did you visit an emergency room

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Status of claim (check all that apply)

 

If claiming disability benefits because of

 

 

1C.

or Urgent

Care facility?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pending

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Approved

 

 

 

 

 

 

pregnancy

 

 

 

 

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Denied

 

 

 

 

Appealed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expected delivery date _______________

If yes, attach copy of Discharge Summary.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you participated in the IMRF Elected

 

Actual delivery date

_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County Officials Plan (ECO)?

2.

Date you last worked

4. Within the past six months, have you been

off work for the same injury or illness?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________________________

 

 

 

 

 

No

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Are you currently employed by an employer outside IMRF?

 

 

 

9. Do you own a business?

No

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, give name, address and telephone of employer:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

Yes

 

 

 

If yes, do you work for the business?

 

 

No

 

 

Yes

 

 

 

 

 

_____________________________________________________

 

 

 

If yes, give name, address and telephone of

business:

 

 

 

 

 

_____________________________________________________

 

 

 

_____________________________________________________

 

 

 

 

_____________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_____________________________________________________

 

 

 

_____________________________________________________

9A. Do you perform any work or other activities for which you receive payment?

 

No

 

 

Yes

 

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_____________________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Name and address of all physicians consulted and date of consultation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Attach additional sheet if needed. Each physician needs to complete IMRF Form 5.42, Physician’s Statement)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of doctor

 

 

 

 

Phone

Address

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

Date of Consultation

 

______________________________________________________________________________________________________________________

 

______________________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Name and address of all hospitals where you were treated, including facility from question 3C

(Attach additional sheet if needed.)

 

Name of hospital

 

 

 

Phone

Address

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

Date of Consultation

 

______________________________________________________________________________________________________________________

 

______________________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Form W-4P Federal Income Tax Withholding Certificate (substitute form)—Complete the following applicable lines:

 

 

 

 

 

 

 

 

 

 

 

 

12a. I elect to have no income tax withheld from my disability payments. (Do not complete lines 12b or 12c.)

....................................................

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12b. I want my withholding from each periodic disability payment to be calculated using the number of allowances

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and marital status shown. (You may also designate an amount on line 12c.)

............................................................................

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____________

 

 

 

 

Single

 

 

 

 

Married

 

 

Married, but withheld at higher single rate

 

 

 

 

 

 

 

 

 

 

 

 

 

(number of allowances)

12c. I want the following additional amount withheld from each periodic disability payment

 

 

 

 

 

 

 

 

 

 

$___________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To all employers, insurance companies, workers’ compensation carriers and all other agencies:

I authorize the Illinois Municipal Retirement Fund, or its representatives, to obtain or view a copy of all employment records, and/or workers’ compensation records. A photostatic copy of this authorization shall be considered as effective and valid as the original. Do not complete

prior to your last day of work.

Signature X

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Completed form may be mailed to: Illinois Municipal Retirement Fund

2211 York Road, Suite 500, Oak Brook Illinois 60523-2337

Member Services Representatives PH 1-800-ASK-IMRF (1-800-275-4673) • FX 630-706-4289 • www.imrf.org IMRF Form 5.40 (Rev. 6/2012)

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Guidelines on how to fill in processingofyour stage 1

2. Just after filling out the previous section, go on to the next part and enter all required particulars in these fields - IMRF Form Rev, and eligible for a tax credit For.

Step # 2 for filling out processingofyour

3. Completing Members Last Name, Street Mailing Address, Telephone, First, Middle Initial, City State and ZIP, Cell Phone, Email, Social Security Number, FILING GUIDELINES Do not file, pregnancy submit this form after, You should file this application, than days, File this form even if you plan, and ATTACHMENT GUIDELINES A copy of is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Members Last Name, Email, and ATTACHMENT GUIDELINES A copy of in processingofyour

It is possible to make errors when completing your Members Last Name, therefore be sure you reread it prior to when you send it in.

4. The next subsection will require your input in the following areas: No Are you currently employed by, Yes If yes give name address and, off work for the same injury or, Yes, Yes Do you own a business No, Yes If yes do you work for the, Yes, If yes please explain, A Do you perform any work or other, Name and address of all, Attach additional sheet if needed, Date of Consultation, CityStateZip, Phone, and Address. Make certain you fill out all of the needed details to move forward.

Part no. 4 in submitting processingofyour

5. As you reach the last sections of this document, you'll find several extra points to complete. Particularly, Form WP Federal Income Tax, a I elect to have no income tax, Single, Married, Married but withheld at higher, number of allowances, c I want the following additional, To all employers insurance, Date, Completed form may be mailed to, Member Services Representatives PH, and IMRF Form Rev should all be filled out.

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