Fillable LOS ANGELES COUNTY FIREMENS RELIEF ASSOCIATION

Fill Online, Printable, Fillable, Blank LOS ANGELES COUNTY FIREMENS RELIEF ASSOCIATION Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

LOS ANGELES COUNTY FIREMENS RELIEF ASSOCIATION

On average this form takes 4 minutes to complete

The LOS ANGELES COUNTY FIREMENS RELIEF ASSOCIATION form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 16 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
LOS ANGELES COUNTY FIREMEN’S RELIEF ASSOCIATION
CLAIM FOR SICK OR INJURY BENEFITS
To the Board of Directors; I______________________________________________ Employee No.____________
(Print Name)
Station No. __________ Shift _____, or other work location _________________________________________
Residing at __________________________________________________________________________________
(Street) (City) (zip) (Telephone)
A member in good standing, I hereby certify that I was unable to perform my regular line of duties or assignment in
the Los Angeles County Fire Department because of: ________________________________________________
(State nature of illness or injury)
from _____________________20_____ to ______________________20_____, inclusive, a period of ______days.
(Date of illness or injury) (Date of return to work)
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 dates as shown in above claim
correspond with Administrative Site records. I have read and understand the above statement.
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. *ALL CLAIMS MUST BE VERIFIED BY AN
“ATTENDING PHYSICIAN’S STATEMENT”.
ATTENDING PHYSICIAN’S STATEMENT
I certify that I attended to the above patient from _________________20 ____ to ______________20 ____,
inclusive. And that his/her disability was due to: _____________________________________________
HE/SHE MAY RETURN TO WORK ON: ___________________________________________________
_____________________________________ __________________
Physician’s Signature Date Signed
____________________________________________________________________________________
(
Physician’s Street) (City) (Zip) (Telephone)
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._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
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
AMOUNTS PAID ON THIS CLAIM
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

LOS ANGELES COUNTY FIREMENS RELIEF ASSOCIATION

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 February 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document