By furnishing this information, you make NO representation regarding the validity of the member's claim for disability benefits.
Work-related: complete this form whether the disabling condition is work-related or not.
Signature: the Authorized Agent's signature is required for all claims.
Social Security Number: print the member's Social Security Number (or IMRF Member ID, if known) on all documents you enclose with this form.
Last date worked: the last day the member was physically present at his or her job; this does not include sick or vacation time.
Instruction sheet: do not return this Instruction sheet; return the form only.
Resignation: if the member resigns, forward a copy of the resignation letter and supporting documents.
| Question | Answer |
|---|---|
| Form Name | IMRF Form 5.41 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 6 min |
| Edition | Rev 02/2013 |
| Complete this form | As soon as the member has stopped working and is expected to remain disabled for thirty (30) days or more |
| Other names | IMRF Form 5.41, IMRF 5.41, Form 5.41, IMRF Form 541, Employer Statement-Disability Claim |
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