Fillable CLAIM FOR HOSPITAL BENEFITS

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CLAIM FOR HOSPITAL BENEFITS

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LOS ANGELES COUNTY FIREMEN’S RELIEF ASSOCIATION
CLAIM FOR HOSPITAL BENEFITS
To Board of Directors; I_________________________________________________ Employee No.____________
(Print Name)
Of Station No. __________ Shift _____, or other work location _________________________________________
Residing at _________________________________________________________________________________ _
(Street) (City) (Zip) (Telephone)
A member in standing, hereby certify that I was admitted to the hospital because of:
___________________________________________________________________________________________
(State nature of illness or injury)
from _____________________20_____ to ______________________20_____
(Date of hospitalization) (Date of discharge)
I understand that the disability for which I am now claiming benefits from the Association is not service
connected. In the event this disability or its cause should hereafter be determined to be service connected. I
will promptly refund all benefits I have received pursuant to this claim.
The hospital claim does not include
the day of discharge. I have read and understand the above statement.
Please include a copy of the hospital discharge papers or a copy of the portion of the
hospital bill, reflecting the date of admission and the date of discharge. No hospital claim
shall be paid without proper supporting documentation.
Members Signature: _______________________________________ Date: __________
(Please sign and date)
Send Check to: __________________________________________________________
(Street Address or P.O. Box)
__________________________________________________________
(city) (Zip)
*SEE REVERSE SIDE FOR INFORMATION AND MAILING INSTRUCTIONS.
DO NOT WRITE IN SPACE BELOW
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
VERIFY: MEMBER __________
DOCTOR __________
PAYROLL _________
Revised 01/08
INFORMATION REGARDING CLAIMS
1. A member shall be entitled to a weekly benefit, upon submission of claim and proof that he/she has been
unable to perform their assigned duties by reason of disability caused by illness, injury or quarantine,
subject to provisions of Section 4203 of by-laws. Schedule of benefits is as follows:
A. A minimum payment of $60.00 per week.
B. As determined annually by the board.
C. Temporary disability benefits shall not be paid for more than sixty weeks. (Section 4209)
2. In order to be entitled to receive benefits, a written claim must be submitted in such form and details as
prescribed by the Board and the claimant must furnish proof in support thereof. (Section 4106)
3. A CLAIM FOR BENEFITS MUST BE SUPPORTED BY THE STATEMENT OF A PHYSICIAN UNLESS
WAIVED BY THE BOARD. (Section 4109)
4. The first day of disability may be counted as the one on which a member was disabled, according to
departmental payroll record, subject to Section 4203. Disability time may include any of the following:
accumulated sick time, holiday time, vacation time or time exchanges. IF DATES CLAIMED ARE
CERTIFIED BY A LICENSED PHYSICIAN. (Section 4206)
5. Claims for benefits must be on file with the Association not later than three (3) months from
(a) conclusion of temporary disability, (b) retirement, (c) classification by the Board of Retirement as
permanent disability, (d) death or (e) termination as the case may be. (Section 4112)
6. NO BENEFITS WILL BE PAID IF SUCH DISABILITY IS ACCEPTED AS SERVICE CONNECTED.
(Section 4203)
7. Mail claims to: Los Angeles County Firemen’s Relief Association
P. O. Box 91-1113
Commerce, CA. 90091
Revised 01/08
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CLAIM FOR HOSPITAL BENEFITS

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Completed 20 February 2022

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