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GOVERNMENT EMPLOYEES RETIREMENT SYSTEM 3438 Kronprindsens Gade, GERS Complex - Ste. 1, St. Thomas, VI GO802-5750 ¢ (340) 776-7703 * Fax (340) 776-4499 3005 Orange Grove, Lat 5, Christiansted, St. Croix, VIO0820-4313 * (840) 773-5480 « Fax (340) 773-5497 www.usvigers.com NON-DUTY DISABILITY GUIDELINES (Governed by Title 3 VIC, Section 710) REQUIREMENTS: e Must be under age 60. ¢ Disability cases must be supported by medical reports including Xrays reports, operative reports, therapy and findings. * Must have nine {9} or more years of credited service. ¢ Disability must cause the member to be totally and permanently incapacitated for service. ¢ Benefits of 2% for each credited year. ¢ Disability must not be job related. ¢ Must be certified disabled by at least two (2} physicians designated by the GERS. ¢ Diseases/IIinesses such as, but not limited to, stroke, renal failure, cancer, physical and mental disability and blindness are used for disability benefits. ¢ Disability cases, incfuding all medical reports, are reviewed by our disability organization, Alternatives for Growth {AFG}, which is on the mainland. AFG advises the GERS on speciality of physician that the member must see, ¢ Disability cases normally take several months. 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 file for disability with the Social Security Administration. ¢ Disability applicant must keep their GERS loan(s} payments current. ¢ Should a disability case be 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 and thoroughly explained to me on by Date GERS Representative Signature of Member GERS-SEN 109B REV 08 GOVERNMENT EMPLOYEES RETIREMENT SYSTEM 3438 Kronprindsens Gade, GERS Complex - Ste. 1, St. Thomas, VI 00802-5750 « (340) 776-7703 * Fax (340) 776-4499 3005 Orange Grove, Lot 5, Christiansted, St. Croix, Vi 00820-4313 « [340] 773-5480 « Fax (340) 773-5497 www.usvigers.com NON-DUTY DISABILITY APPLICATION PERSONAL INFORMATION: Name {Last} (First) ( Middle) Mailing Address Physical Address Social Security # Date of Birth Home Phone # Cell Phone # Are you married? Yes No If yes, Spouse’s Name EMPLOYMENT INFORMATION: Place of Employment Work Address Work Phone # Ext. Approximate years of service Employee # Position Title Are you a Veteran? Yes No Name and Title of Immediate Supervisor Last date you worked Date removed from payroll due to disability YOUR DISABILITY: Nature of your disability Date you first became disabled Date first treated for this disability Have you been completely unable to work during your disability? Yes No GERS-BEN 1098 REV 08 YOUR ATTENDING PHYSICIAN(S): Name of your physician Physician’s address Phone # Date of first treatment 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 treatment 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 treatment Nature or cause of treatment 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 yes, has it been approved or rejected? Approved Rejected If it has been approved, please submit together with this application the Certificate of Social Security Insurance Award. GERS-BEN 71098 REV 08 AUTHORIZATION FOR RELEASE OF INFORMATION: | hereby apply for non-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 information 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, | hereby specifically authorize the release of any records which may exist concerning 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 Security Administration, Workers’ Compensation 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 Lega! Guardian) Name of Legal Guardian Mailing Address Physical Address Telephone # APPLICANT'S ACKNOWLEDGMENT: | hereby apply for a NON-DUTY DISABILITY ANNUITY from the Employees’ Retirement 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 statement may disqualify me for benefits, and that the Board of Trustees shall have the right to recover any payments made to me. | also agree that | will advise the Employees’ Retirement System of my return to any type of work, and | will return any payments to which | am not entitled by reason of my return to work, termination of disability, or receipt of benefits from other sources listed above. Signature of Witness Signature of Applicant Date Date GERS-BEN 1098 REV 08