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PERAC Disability Forms

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Disability Forms for Members

Disability Application Glossary of Terms, Open PDF file, 126.97 KB (English, PDF 126.97 KB)
Disability Retiree Earned Income Worksheet, Open PDF file, 231.28 KB (English, PDF 231.28 KB)
Disability Retirement Application, Open PDF file, 445.85 KB (English, PDF 445.85 KB)
Disability Retirement Benefits for Veterans, Open PDF file, 104.73 KB (English, PDF 104.73 KB)
Instructions for Submitting the Annual Statement of Earned Income, Open PDF file, 689.79 KB (English, PDF 689.79 KB)

Disability Forms for Administrators

Accidental Disability Retirement Checklist, Open PDF file, 85.8 KB (English, PDF 85.8 KB)
Disability Retirement Application, Open PDF file, 445.85 KB (English, PDF 445.85 KB)
Disability Transmittal to the Commission, Open PDF file, 242.79 KB (English, PDF 242.79 KB)
Notice of Retirement Board Action on Disability Application, Open PDF file, 73.17 KB (English, PDF 73.17 KB)
Notice to PERAC of Reinstatement of Duties, Open PDF file, 251.5 KB (English, PDF 251.5 KB)

Disability Forms for Employers

Employer Statement for Disability Retirement Application, Open PDF file, 368.29 KB (English, PDF 368.29 KB)
Involuntary Retirement Application, Open PDF file, 421.97 KB (English, PDF 421.97 KB)

Disability Forms for Physicians

Certificate for Accidental Disability (Heart), Open PDF file, 34.26 KB (English, PDF 34.26 KB)
Certificate for Accidental Disability (Lung), Open PDF file, 33.29 KB (English, PDF 33.29 KB)
Commonwealth Terms and Conditions, Open PDF file, 62.04 KB (English, PDF 62.04 KB)
Massachusetts Substitute W-9 Form, Open PDF file, 270.4 KB (English, PDF 270.4 KB)
Physician's Statement Pertaining to a Member's Disability Retirement Application, Open PDF file, 357.45 KB (English, PDF 357.45 KB)
Regional Medical Panel Certificate, Open PDF file, 591.76 KB (English, PDF 591.76 KB)

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