GOVERNMENT EMPLOYEES RETIREMENT SYSTEM



5428 Kronprindsess Gad=, GEAS Complex -She. 1, 8s. "homaa Vi 00802-5760 » (840) 775 7708 « Fax [S40] 772-1499

3005 Orange Grove, Lot 5, Ghristiansted, St Croix. VICDS320-43°S + (840) 773-5480 = Fax (240) 770-545"



VUE Usvigers .COM



DUTY DISABILITY GUIDELINES

(Governed by Title 3 VIC, Section 708)



REQUIREMENTS:



® No age limit and no limit on credited years of service.



* Disability cases must be supported by medical reports including X-rays reports, operative reports, therapy and

findings.



* Member must complete the Employer's First Report and Employee's Notice of Injury.



* Must file Application within six [B] months with the GERS once the member's physician states that he,‘she is totally

disabled,



* Disability must cause the member to be totally and permanently incapacitated for service.

® Benefits of 75% of last salary.



* Disability must be job related.



* Must be certified disabled by at least one (1) physician designated by the GERS.



* Dury disability must be a result of bodily injuries sustained or a hazard undergone while in the performance and within

the scope of duties, if such injuries or hazard were not the consequences of willful negligence.



* (Disability benefits are offset by amounts received from VWerkers’ Compensation Administration.



* (Disability cases, including all medical reports, are reviewed by our disability organization, Alternatives for Growth

[AAG], which is.on the mainland. AFG advises tha GEAS on speciality of physician that the member must see.



* Disability cases normally take several mornt.hs.

SPECIAL NOTES:



* Member must not resign or retire until case is completed by the GERS,



* Disability applicant must contact the Group Health Insurance Office for continued health coverage.

* Member may also ‘ile for disability with the Social Securnty Adrninistration.



* Disability applicant must keep their GEARS Inan[s) payments current.



* Should a disability case he approved, contributions due the System for service credit must be paid prior to being

placed on the Annuity Payroll.



| hereby acknowledge that the preceding guidelines were read anc thoroughly explained to me



on by

Date GERS Representative



Signature of Member



GERE-SEN TUE HEW Lia

GOVERNMENT EMPLOYEES RETIREMENT SYSTEM



3438 Kooncrindsens Gede, GERS Comp ex - Ste. 4, St. Thomas, VI OOBO2-S75D » (540) 776-7703 » Fax (340) 7754498

3005 Orange (rove, Lot 3, Chnstisnsbed. St. Coin, Vl 00829-4213 » [4D] 775480 + Fax (S40) 773-5487



WA USVI SCOT]



DUTY DISABILITY APPLICATION



PERSONAL INFORMATION:



Name



[Last] (First) ( Middle]

Mailing Address



Physical Address



Social Security # ee Date of Birth

Home Phone # _ _ Cell Phone #

Are you rmarried? Yes __ _ No Fyes, Spouse's Name



EMPLOYMENT INFORMATION:



Place of Employment



Work Address



Work Phone # Ext.



Approximate years of service Employer #.



Position Title Are youa Veteran? Yes No



Name and Title of Immediate Supervisor



Last day you worked



Date removed from payroll due to disability



YOUR DUTY-RELATED DISABILITY:



Nate you have been advised by your physician that your disability is permanent and you are totally incapacitated for

Service



Date your duty disability occurred



Where and how did it occur?



Is Employer's First Report and Employees’ Notice of Injury attached to this application? Yes No



Was the Employer's First Report and Employees’ Notice of Injury submitted to tha Department of Labor, Workers’

Compensation Administration? ‘Yes No



Are you receming benefits fram the Department of Labor VWVorkers’ Gompensation Administration? Yes No



EHS BEM 9044, BEY OA

Are you aware that if your application is approved, whatever benefits you received fram the

Department ef Labor, Workers’ Compensation Administration will be offset by the GEAS? Yes No



Name of witness to accident



Address of witness



Name of witness to accident



Address of witness



Assigned duties at time of disability



Nature of your disability



Date you first became disabled _



Date first treated for this disability



Have you heen completely unable to work during your disability? Yas Neo



YOUR ATTENDING PHYSICIAN(S]:



Name of your ohysician



Physician's address



Phone # Date of first treatrnent



Please list other Medical’ Psychological Treatment of all physicians consulted for medical or psychological treatment

within the last two years [treatment that was not directly related to your current disabling condition):



Name of your physician



Physician’s address __



Phone # Date of first treatment



Nature or cause of treater



Name of your physician



Physician's address



Phone #. Date of first treatment



Nature or cause of treatment



Name of your physician __



Physician's address



Phone #_ Date of first treamment



Nature or cause of treatment. _



GENS-BEN 1054, ACY CS

SOCIAL SECURITY ADMINISTRATION:



Have you applied for Social Security Disability? Yes - No

If yes, have you received a decision on your application? ‘Yes No

If yas, has it bean approved or rejected? Approved Rejected



if it has been approved, please submit together with this application the Certificate of Social Security Insurance Award.



AUTHORIZATION FOR RELEASE OF INFORMATION:



[hereby apply for duty disability retirement benefits. This application is being made because of a disability which incapacitates

me for the performance of any useful work and | affirm that all infarmmation and statements are true and correct to the

best of my knowledge.



| hereby authorize any physician, hospital, or clinic to give full and complete information concerning me or my medical

condition, including any prior history, to the Employees’ Retirement System of the Government of the Virgin Islands, or its

authorized representative.



In addition to the above general medical release, | haraby specifically authorize the release of any records which may exist

cancerning me, including, but not limited to, employment or personnel records with previous employers, records with a

School Board, Community College, or Public School System, or records with other Retirement Systems, the Veteran's

Administration, Social Securmty Administration, VWWorkers Gompensation or any other records which a personal release

signed by me may be required. Please cooperate with the bearer of this release. This Authorization for Release of

Information is valid throughout the duration of my claim.



signed Date

[Employee or Legal Guarchian)



Name of Legal Guardian



Mailing Address



Physical Address



Telephone #



APPLICANT'S ACKNOWLEDGMENT:



| hereby apply fora DUTY DISABILITY ANNUITY from the Employees’ Retirament System of the Government of the Virgin

islands. The above statements are true to the best. of my knowledge and belief. | understand that a false statament may

disqualify me for henefits, and that the Board of Trustees shall have the right to racoyer any payments made tome. |also

agree that. | will acvise the Employees’ Aetirarment System of my return to any tyos of work, and | will raturmn any payments

to which barn not entitled by reason ef my return to work, termination of disability, or receipt of banefits from other sources

listed above.



Signature of Witness Signature of Applicant



Date Date



GERSEEN OBA REV Ce