840 CMR: PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION
840 CMR 10.00: STANDARD RULES FOR DISABILITY RETIREMENT

10.06: Proceedings for Ordinary or Accidental Disability Retirement; Applications; Additional Information

Proceedings for ordinary or accidental disability retirement may be brought by filing an application with the retirement board and with the employer. The application shall consist of the forms prescribed by 840 CMR 10.06, and shall be considered filed as of the date upon which the applicant completes and submits all the required forms to the retirement board.. If the retirement board or the Commission believes any part of the application contains false, fictitious or fraudulent information, the board or the Commission shall notify the Attorney General or the appropriate district attorney.

1) Voluntary Retirement. Any member in service who becomes totally and permanently unable to perform the essential duties of his or her job under the circumstances described in M.G.L. c. 32, § 6 (relating to ordinary disability) or § 7 (relating to accidental disability) may file an application for retirement. Every member-applicant shall also file:

(a) A sworn statement indicating the members intent to retire;
(b) A certificate from a licensed medical doctor;
(c) A written statement authorizing release of information from the Federal Internal Revenue Service and the Department of Revenue relative to the annual gross earned income of the member in accordance with M.G.L. c. 32, §§ 6(1) and 7(1);
(d) If the application is for accidental disability retirement, a sworn statement on Form 10-3 of the circumstances of the event or hazard undergone from which the personal injury was sustained upon which the disability retirement allowance is claimed;
(e) The member's sworn statement of the member's duties of employment and the specific duties the member is now unable to perform as a result of the disability claimed:
(f) A statement of the member's education and training, employment history and off-duty physical activities:
(g) Authorizations on such other form as may be required by a person, institution or other agency having custody of the member's records, for release of medical or insurance records relating to the member as follows:

1. records of the member's personal physicians and of the physician submitting the certificate described in 840 CMR 10.06(1)(b);
2. records of all physicians or medical institutions examining or treating the member for the condition or personal injury upon which the application is based;
3. records of all physical examinations performed within the five year period prior to the application or, if none are available for that period, the most recent;
4. the member's workers’ compensation records or, if applicable, any records in connection with application for or receipt of benefits pursuant to M.G.L. c, 41, § 111F; 5. the member's medical records for the last five years;
6. the accident or claim reports for the last five years of any insurer in connection with the personal injury sustained or the hazard undergone upon which the application is based;

(h) Authorizations permitting the physicians and medical institutions described in 840 CMR 10.06(1)(g)2. to further explain the records, treatment performed, or statement or prognosis.

(2) Involuntary Retirement. The department head of any member in service who becomes totally and permanently unable to perform the essential duties of his or her job under the circumstances described in M.G.L. c. 32, § 6 (relating to ordinary disability) or § 7 (relating to accidental disability) may file an application for retirement on Form 10-2A. Department head applicants shall also file the statements by the department head or employer (Form 10-7) described in 840 CMR 10.07 and any medical information available to the department head or employer on which the application is based.

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