Imrf Form 5 41 – Fill Out and Use This PDF

EMPLOYER STATEMENT—DISABILITY CLAIM

IMRF Form 5.41 (Rev. 02/2013)

Instructions for Employer:

By furnishing this information, you make NO representation regarding the validity of the member’s claim for disability benefits.

1.Complete this form:

a.As soon as the member has stopped working and is expected to remain disabled for thirty (30) days or more.

b.Whether the disabling condition is work-related or not.

2."Last date the member actually worked" refers to the last day the member was physically present at his or her job. This does not include sick or vacation time.

3."Last date the member was or will be paid" refers to the last day for which the member will receive wages (or compensation), including sick and vacation time.

4.The Authorized Agent’s signature is required for all claims.

5.Print the member’s Social Security Number (or IMRF Member ID, if known) on all documents you enclose with this form.

6.Do not return this Instruction sheet; return the form only.

Disability benefit payments can be reduced or terminated if the member:

Receives wages (or compensation) in any month he or she is disabled.

Resigns. Please refer to the IMRF Authorized Agent Manual, Section 5.40D(5), “Resignations of Disabled IMRF Members.”

If the member resigns, forward a copy of the resignation letter and supporting documents. Include meeting minutes accepting the resignation.

NOTE: Please provide complete and accurate information.

Incomplete or inaccurate information may delay claims processing.

Illinois Municipal Retirement Fund

2211 York Road Suite 500 Oak Brook Illinois 60523-2337

Member Services Representatives 1-800-ASK-IMRF (1-800-275-4673) Fax: (630) 706-4289

www.imrf.org

IMRF Form 5.41 Instructions (Rev. 02/2013)

EMPLOYER STATEMENT—DISABILITY CLAIM

Please provide complete and accurate information. Incomplete or inaccurate information may delay claims processing.

EMPLOYER NAME					EMPLOYER IMRF ID NUMBER
MEMBER’S NAME			SOCIAL SECURITY NUMBER (OR IMRF MEMBER ID, IF KNOWN)
DATE OF BIRTH (MM/DD/YYYY)			OCCUPATION (ATTACH COPY OF JOB DESCRIPTION)
Last date member actually worked (MM/DD/YYYY)			Last date member was/will be paid wages or compensation (MM/DD/YYYY)
(Not including Sick or Vacation days.)			(Including Vacation Pay, Sick Pay, etc.) NOT the date of the member's paycheck.

..............Within the past 6 months, has the member been off work for the same injury or illness?				No			Yes
TO BE COMPLETED FOR MEMBERS WITH LESS THAN FIVE YEARS OF IMRF SERVICE CREDIT
Did the member undergo a pre-employment medical examination?				No			Yes

(If yes, attach a copy of doctor's report to this form and print the member’s Social Security number or IMRF Member ID, if known on the report)

................................................................................................Is the member an Elected Official?			No				Yes
If yes, does the member participate in the ECO Plan			No				Yes
(If yes, complete “To be completed for ECO Members Only” below)
TO BE COMPLETED FOR ECO MEMBERS ONLY
Please enter the dates for the ECO member’s term of office
If the member is not currently in office, provide dates for LAST elected county office held	FROM (MM/DD/YYYY)						TO (MM/DD/YYYY)
Please enter the member’s final annual salary earned as a member of the ECO Plan		$ __________________________. .
Please enter the member’s annual stipend(s) as a member of the ECO Plan		$ __________________________. .
Is the member a seasonal employee			No				Yes
If yes, did the member elect to be paid over 12 months?			No				Yes
Has the member returned to work?			No				Yes

If yes, please indicate the date (MM/DD/YYYY) ________________________________ and attach the Physician’s Release.

If no, give reason: __________________________________________________________________________________________

................................................................................................Has the member been terminated?		No		Yes

If yes, please indicate the date (MM/DD/YYYY) ________________________________

If yes, give reason: _________________________________________________________________________________________

Was a claim made for workers' compensation or occupational disease benefits?				No	Yes
If a claim has been made, what is the status of the claim:	Approved	Denied	Pending		Appealed
If the claim was approved, what is the weekly benefit amount? $ ___________ per week. Benefits start date: ________________
					(MM/DD/YYYY)

If workers’ compensation or occupational disease benefits have ceased, provide termination date of benefits: ________________

				(MM/DD/YYYY)
Name of workers’ compensation carrier			Daytime Telephone Number (with Area Code)
			(	)
Address	City, State and ZIP

	Daytime Telephone Number. (with Area Code)				Email
	(	)
			Illinois Municipal Retirement Fund
		2211 York Road		Suite 500 Oak Brook Illinois 60523-2337

Member Services Representatives 1-800-ASK-IMRF (1-800-275-4673) Fax: (630) 706-4289

www.imrf.org

IMRF Form 5.41 (Rev. 02/2013)