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PERAC Disability Forms

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Disability Forms for Members

Open PDF file, 53.76 KB,  Authorization to Use or Disclose Protected Health Information (English, PDF 53.76 KB)
Open PDF file, 126.97 KB,  Disability Application Glossary of Terms (English, PDF 126.97 KB)
Open PDF file, 172.83 KB,  Disability Retiree Earned Income Worksheet (English, PDF 172.83 KB)
Open PDF file, 433.55 KB,  Disability Retirement Application (English, PDF 433.55 KB)
Open PDF file, 104.73 KB,  Disability Retirement Benefits for Veterans (English, PDF 104.73 KB)
Open PDF file, 124.94 KB,  Instructions for Submitting the Annual Statement of Earned Income (English, PDF 124.94 KB)
Open PDF file, 329.47 KB,  Waiver of Applicant Attendance at Medical Panel Examination During COVID-19 Pandemic (English, PDF 329.47 KB)

Disability Forms for Administrators

Open PDF file, 85.8 KB,  Accidental Disability Retirement Checklist (English, PDF 85.8 KB)
Open PDF file, 207.06 KB,  Disability Retiree Current Information Form (English, PDF 207.06 KB)
Open PDF file, 433.55 KB,  Disability Retirement Application (English, PDF 433.55 KB)
Open PDF file, 242.79 KB,  Disability Transmittal to the Commission (English, PDF 242.79 KB)
Open PDF file, 73.17 KB,  Notice of Retirement Board Action on Disability Application (English, PDF 73.17 KB)
Open PDF file, 245.59 KB,  Notice to PERAC of Reinstatement of Duties (English, PDF 245.59 KB)
Open PDF file, 276.36 KB,  Physician's Statement Pertaining to a Member's Disability Retirement Application (English, PDF 276.36 KB)
Open PDF file, 334.3 KB,  Waiver of Applicant Attendance at Medical Panel Examination During COVID-19 Pandemic (English, PDF 334.3 KB)

Disability Forms for Employers

Open PDF file, 333.61 KB,  Employer Statement for Disability Retirement Application (English, PDF 333.61 KB)
Open PDF file, 311.79 KB,  Involuntary Retirement Application (English, PDF 311.79 KB)
Open PDF file, 332.07 KB,  Waiver of Applicant Attendance at Medical Panel Examination During COVID-19 Pandemic (English, PDF 332.07 KB)

Disability Forms for Physicians

Open PDF file, 62.04 KB,  Commonwealth Terms and Conditions (English, PDF 62.04 KB)
Open PDF file, 270.4 KB,  Massachusetts Substitute W-9 Form (English, PDF 270.4 KB)
Open PDF file, 517.28 KB,  Regional Medical Panel Certificate (English, PDF 517.28 KB)

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