DALA’s Recommended Order for Exhibits
Submitted by Retirement Boards in Disability Cases

1. Notice of Retirement Board Action on Disability Retirement Application or letter of decision from the Retirement Board denying the application.

2. Claim of appeal letter from Petitioner.
3. Application for Disability Retirement, multi-page PERAC form containing:
• signed application
• Statement of Applicant’s Duties
• Your Employment History
• Statements About Your Background, Qualifications & Recent Physical Activities
• Reason for Accidental Disability
• Incident Reports, Witness Data
• Other Actions Taken, Workers’ Compensation
• Emergency Medical Treatment
• Hospitals and Medical Facilities
• Physicians
• Primary Treating Physician, Other Conditions, Attorney Information
• Insurance Coverage
4. Physician’s Statement, Certification of Applicant’s Disability Status
5. Employer’s Statement, multi-page PERAC form containing:
• Applicant’s Current Employment
• Medical Condition & Current Employment
• Circumstances Related to Claim of Accidental Disability
• Early Intervention Plan
• Workers’ Compensation
• Required Signatures
6. Any Job Description not attached to Employer’s Statement
7. Any Notices of Injury not attached to Employer’s Statement
8. Transmittal of Background Information to a Regional Medical Panel (PERAC’s form previously identified as Form 1010)

9. Medical Panel Certificate and Report
10. Medical records in chronological order (please remove duplicates!)