Memorandum  PERAC Memo #15: Violent Act Injury Disability – Updated Forms

Date:	06/03/2025
Referenced Sources:	PERAC Website

PERAC Memo #15, 2025

To All Retirement Boards:

TO:                  All Retirement Boards

FROM:            Bill Keefe, Executive Director

RE:                  Violent Act Injury Disability – Updated Forms

DATE:            June 3, 2025

On July 31, 2024, Governor Healey signed Chapter 149 of the Acts of 2024, “An Act Relative to Disability Pensions and Critical Incident Stress Management for Violent Crimes” (“Violent Act Injury Disability”). This Act created an enhanced new type of G.L. c. 32, Section 7 accidental disability retirement benefit for firefighters, emergency medical technicians, licensed health care professionals and certain police officers[1] who become permanently physically disabled with a catastrophic, life-threatening or life-altering bodily injury disability as the result of an intentional violent physical act by means of a dangerous weapon.  Please see PERAC Memorandum #28 of 2024 for more information regarding this Act.

Due in part to this new legislation, PERAC is reviewing and updating its regulations, and intends to include definitions that may assist the retirement boards with determining whether someone is eligible for the enhanced Violent Act Injury Disability benefit. 

To implement the provisions of the Act, PERAC edited and amended several of the forms associated with the disability retirement process to accommodate the specific requirements of the Violent Act Injury Disability benefit.  This memorandum will highlight the changes to those forms.  Please note, we do not expect that retirement boards will receive many applications for Violent Act Injury Disability, given the limiting eligibility requirements for this enhanced benefit. 

The amended forms related to the Violent Act Injury provision include:

1. Member’s Application for Disability Retirement
2. Physician’s Statement
3. Employer’s Statement Pertaining to an Application for Disability Retirement
4. Regional Medical Panel Certificate

For your convenience, the amended forms discussed in this memorandum are linked above, with highlights below to the areas amended.  These forms are available on our website.  Further, in addition to the forms discussed, all PERAC forms have been updated, regardless of whether they concern or mention the Violent Act Injury, to account for PERAC’s recent change of address. 

Member’s Application for Disability Retirement

The Member’s Application for Disability Retirement contains several changes related to the Violent Act Injury Disability benefit.  Please know that an applicant for the enhanced benefit must meet the requirements for a regular Section 7 Accidental Disability Retirement benefit of incapacity, permanence and causation, before the criteria for the enhanced benefit can be examined.  Changes to this form include the following:

• On page 2, in the “Introduction” section of the Member’s Application for Disability Retirement, it provides:

Qualification for Violent Act Injury

• In order to qualify for a disability under the Violent Act Injury provision a certain police officer, firefighter, EMT or other licensed health care professional must demonstrate, and the retirement board must determine, that all three of the following elements are established:

1. That they suffered a catastrophic, life-threatening or life-altering bodily injury;
2. That the injury was the direct and proximate result of a violent attack upon a person, which means that the injury must result from an intentional physical act, and not result from an accident or from negligence; and 
3. That the attack was by means of a dangerous weapon, which is designed for the purpose of causing serious injury or death, including, but not limited to, a firearm, knife, automobile or explosive device.

• On page 4, under the section headlined “Please read before selecting a disability type and signing below,” it contains the following two bullet-points:
• If I apply for Violent Act Injury Disability Retirement, I must answer all the questions on this application. I must be a certain police officer, firefighter, EMT or other licensed health care professional to potentially qualify for this enhanced benefit, and I must demonstrate all of the above, as well as that I suffered a catastrophic, life-threatening or life-altering bodily injury that was the direct and proximate result of an intentional violent attack upon my person by means of a dangerous weapon, which was designed for the purpose of causing serious injury or death, including, but not limited to, a firearm, knife, automobile or explosive device. 
• If I apply for a Violent Act Injury Disability and PERAC approves either a Violent Act Injury Disability application, Accidental Disability application or an Ordinary Disability application for me based on the Retirement Board’s findings, the Regional Medical Panel Report and other evidence, then I may be retired for Violent Act Injury Disability, Accidental Disability or Ordinary Disability, respectively.
• On page 4, under the heading entitled: “I apply to be retired on the basis of the following Disability,” the applicant may choose “Violent Act Injury” as the basis. 
• On page 8, under the heading entitled “Please identify the reason for your disability,” the applicant is given another opportunity to choose “Violent Act Injury” as the reason. 
• Page 9 provides the applicant with the opportunity to describe the injury that is the basis for their claim for Violent Act Injury disability benefits.  Only applicants for the Violent Act Injury disability benefit must complete this section, which provides:

The following questions are ONLY if you are applying for Violent Act Injury Disability

Please describe the following: 

1. The catastrophic, life-threatening or life-altering permanent bodily injury you sustained:
2. The violent and intentional attack that caused such injury:
3. The dangerous weapon that was used during such violent and intentional act:

Physician’s Statement

In addition to answering the questions of incapacity, permanence and causation, the Physician who answers and completes the Physician’s Statement Pertaining to a Member’s Application for Disability Retirement (“Physician’s Statement”) must answer additional questions to determine whether an applicant may be entitled to a Violent Act Injury Disability benefit. In order to accommodate for these additional questions, PERAC has amended its form to include the following:

• On page 1, it provides:

Are there terms particular to the legal process of disability retirement that the physician should consider when completing the Physician’s Statement? 

If Yes, please review the last two pages of the Physician’s Statement.  Definitions are included for: Accidental Disability, Ordinary Disability, Violent Act Injury Disability, Risk of Re-Injury, Aggravation of a Pre-Existing Condition, and the Permanency Standard.

• On page 3, under the “Introduction” section, it provides:
  • You are asked to answer yes or no to questions (1), (2), (3A), (4), (5), and (6) if the applicant is filing for Violent Act Injury Disability.
• Page 3 further provides:

Applications for Violent Act Injury Disability 

• The physician submitting this form for a member who is applying for Violent Act Injury Disability benefits must determine that the applicant suffered catastrophic, life-threatening or life-altering permanent bodily injuries as a result of a violent physical attack by means of a dangerous weapon designed for the purpose of causing serious injury or death, including, but not limited to, a firearm, knife, automobile or explosive device.
• Psychological injuries are not eligible for Violent Act Injury Disability benefits. 
• Page 9 should only be completed by the Physician if the member is applying for Violent Act Injury Disability benefits.  It provides:

Violent Act Injury Disability – complete pages 8 and 9 only if member is applying for this benefit. Please answer all questions.

Question #4 – Injury:

Did the applicant sustain a catastrophic, life-threatening or life-altering permanent bodily injury?                           YES               NO               

 If YES, please describe how below:                             

Question #5 – Violent Attack:

Was said injury the direct and proximate result of a violent and intentional physical attack upon the applicant?        YES               NO                           

If YES, please describe the violent physical attack below, including in your description the date, time, location witnesses and other pertinent information about the attack:                            

Question #6 – Dangerous Weapon:

Was the attack by means of a dangerous weapon designed for the purpose of causing serious injury or death?      YES              NO                                                    

If YES, please identify the weapon:

• Page 12 contains definitions, including the following:

Violent Act Injury Disability
In an application for Violent Act Injury Disability, certain limited applicants (firefighters, emergency medical technicians, licensed health care professionals and certain police officers) assert that he or she suffered catastrophic, life-threatening or life-altering permanent bodily injuries as a result of a violent physical attack by means of a dangerous weapon, which is designed for the purpose of causing serious injury or death, including, but not limited to, a firearm, knife, automobile or explosive device. Psychological injuries are not eligible for Violent Act Injury Disability benefits.

Employer’s Statement

In order to assist the Regional Medical Panel and the retirement board in determining whether an applicant may be entitled to a Violent Act Injury Disability benefit, the Employer’s Statement now includes the following:

• On page 8, the Employer’s Statement provides:

Violent Act Injury Disability

Added to the retirement law in 2024, G.L. c. 32, §§ 1 and 7 establish an enhanced accidental disability retirement benefit for certain members who suffer catastrophic, life-threatening or life-altering permanent bodily injuries due to a violent physical attack by means of a dangerous weapon, which is designed for the purpose of causing serious injury or death, including, but not limited to, a firearm, knife, automobile or explosive device. Psychological injuries are not eligible for Violent Act Injury Disability benefits.

Answer ONLY if the Applicant is Applying for Violent Act Injury Disability

1. Injury:

Did the applicant sustain a catastrophic, life-threatening or life-altering permanent bodily injury?                                       YES               NO                                    

If YES, please describe such injury:                     

2. Violent Physical Attack:

Was said injury the direct and proximate result of a violent and intentional physical attack upon the applicant?                  YES               NO                                                              

If YES, please provide the following:

1. The date of the attack:

                                    

2. The location of the attack:

3. The names of any witnesses:

4. The details of the attack:

3. Dangerous Weapon:

Was the attack by means of a dangerous weapon designed for the purpose of causing serious injury or death?                 YES               NO                                   

If YES, please identify the weapon below:                                    

Regional Medical Panel Certificates

In addition to answering the questions of incapacity, permanence and causation, the Medical Panel must answer additional questions to determine whether an applicant may be entitled to a Violent Act Injury Disability benefit.  To accommodate for these additional questions, PERAC has drafted an entirely new Certificate for applications for Violent Act Injury Disability.[2]  The form is headlined: Regional Medical Panel Certificate – Joint/Single (Violent Act). 

Pages 1-3 on the Certificate are identical to what is written on a regular Section 7 Accidental Disability Certificate.  Beginning on Page 4, the Certificate contains the following, which is specific to Violent Act Injury applications:

Added to the retirement law in 2024, G.L. c. 32, §§ 1 and 7 establish an enhanced accidental disability retirement benefit for certain members who suffer catastrophic, life-threatening or life-altering permanent bodily injuries due to a violent physical attack by means of a dangerous weapon, which is designed for the purpose of causing serious injury or death, including, but not limited to, a firearm, knife, automobile or explosive device. Psychological injuries are not eligible for Violent Act Injury Disability benefits.

Please answer all questions below. Questions 4, 5, and 6 are required on applications for Violent Act Injury Disability.

Question #4 – Injury

Please consider the following before responding to Question #4.  This should be discussed in detail in your narrative:

• Did the applicant sustain a permanent bodily injury?
• Was the injury catastrophic?
• Was the injury life-threatening?
• Was the injury life-altering?
• As a result of this injury, does the applicant suffer from significant limitations and/or the inability to complete activities of daily living (i.e., cooking, cleaning, bathing, driving, etc.)

Based upon your review of above:

Did the applicant sustain a catastrophic, life-threatening or life-
altering permanent bodily injury?                                                      Yes                No

Question #5 – Violent Physical Attack

Please consider the following before responding to Question #5.  This should be discussed in detail in your narrative:

• Was the injury a direct and proximate result of an intentional physical attack?
• Was the injury the result of an accident or negligence?

Based upon your review of above:

Was said injury the direct and proximate result of a violent and 
intentional attack upon the applicant?                                               Yes                No

Question #6 – Dangerous Weapon

Please consider the following before responding to Question #6.  This should be discussed in detail in your narrative:

• Was a dangerous weapon utilized in the attack?
• Did a dangerous weapon cause serious injury or harm?
• Was the dangerous weapon designed for the purpose of causing serious injury or death?
   

Based upon your review of above:

Was the attack by means of a dangerous weapon designed for the 
purpose of causing serious injury or death?                                       Yes                No

Page 8 of the Certificate pertains to medical panelists who hold the minority opinion of the panel and requires such a panelist to answer the same Questions 4, 5 and 6.

The above forms are dated May 2025. Please discontinue use of any forms with an earlier date. We trust the foregoing will be of assistance.  If you have any questions, please feel free to contact Deputy Executive Director Ken Hill at 617-591-8945 or at [e-mail]. Thank you.

1. State Police retire under Section 26 of Chapter 32 and are thus not eligible for benefits under the Violent Act Injury provision provided for in Section 7.
2. Technically, PERAC has drafted two new certificates: one for joint panels, and the other for single panels, but the language and questions concerning the Violent Act Injury Disability are identical on both forms.