IMRF Form 5.41: Illinois Employer Statement-Disability Claim

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.

Enter the Employer Name and the Employer IMRF ID Number.

Enter the Member's Name and the Social Security Number (or IMRF Member ID, if known).

Enter the Date of Birth (MM/DD/YYYY) and the Occupation, and attach a copy of the job description.

Enter the last date member actually worked (MM/DD/YYYY), not including sick or vacation days.

Enter the last date member was/will be paid wages or compensation (MM/DD/YYYY), including vacation pay, sick pay, etc., NOT the date of the member's paycheck.

Mark No or Yes: within the past 6 months, has the member been off work for the same injury or illness?

For members with less than five years of IMRF service credit, mark No or Yes: did the member undergo a pre-employment medical examination? 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.

Mark No or Yes: is the member an Elected Official?

If yes, mark No or Yes: does the member participate in the ECO Plan? If yes, complete the section to be completed for ECO members only.

For ECO members only, enter the dates for the ECO member's term of office; if the member is not currently in office, provide dates for the last elected county office held, FROM (MM/DD/YYYY) TO (MM/DD/YYYY).

For ECO members only, enter the member's final annual salary and the member's annual stipend(s) earned as a member of the ECO Plan.

Mark No or Yes: is the member a seasonal employee? If yes, mark No or Yes: did the member elect to be paid over 12 months?

Mark No or Yes: has the member returned to work? If yes, indicate the date (MM/DD/YYYY) and attach the Physician's Release.

If the member has not returned to work, give the reason.

Mark No or Yes: has the member been terminated? If yes, indicate the date (MM/DD/YYYY) and give the reason.

Mark No or Yes: was a claim made for workers' compensation or occupational disease benefits?

If a claim has been made, mark the status of the claim: Approved, Denied, Pending or Appealed. If the claim was approved, enter the weekly benefit amount.

Enter the benefits start date (MM/DD/YYYY). If workers' compensation or occupational disease benefits have ceased, provide the termination date of benefits (MM/DD/YYYY).

If a claim has been made, enter the Name of workers' compensation carrier, its Daytime Telephone Number (with Area Code), Address, and City, State and ZIP.

Sign on the Authorized Agent's Signature line and enter the Date (MM/DD/YYYY). Enter the Daytime Telephone Number (with Area Code) and Email.