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(A) Application Required: To seek benefits under the Act, a full- time police officer, or in the event of the death or incapacity of the police officer, a family member of the injured or deceased police officer, must file with the Police Chief a fully completed PSEBA application, in writing, within thirty (30) calendar days of the granting of a line-of-duty disability pension, or within thirty (30) calendar days of the date of the adoption of this section 8-1-4 in the event that the employee has filed a pension claim prior to the date of adoption of this section 8-1-4, whichever is later.
The application must include the name of employee, date of hire, detailed information regarding the incident (including date, time, place, nature of injury, any other factual circumstances surrounding said incident giving rise to said claim), witnesses to the incident, witnesses the applicant intends to call at the PSEBA hearing, information and supporting documentation filed with the Pension Board by the applicant or identified as exhibits by the Pension Board and any Pension Board determination or ruling, documents/information supporting the PSEBA eligibility requirements. Failure to timely file the fully completed application along with submittal of other required information shall result in a forfeiture of the benefits under PSEBA.
Upon request, the Police Chief, or his designee, shall furnish a Public Safety Employee Benefit Act application to the applicant.
(B) Sworn Statement Required: The PSEBA application shall include a sworn and notarized statement explaining how the disabling injury or death directly resulted from:
1. A police officer's response to fresh pursuit;
2. A police officer's response to what is reasonably believed to be an emergency;
3. A police officer's response to an unlawful act perpetrated by another; or
4. A police officer's participation during the investigation of a criminal act.
(C) Medical Release Required: A signed PSEBA medical release authorizing the collection of medical information related to the incident including, but not limited to, the disability pension proceedings, worker's compensation records and medical records, must be submitted with the PSEBA application. The PSEBA medical information release must specify the name, address, e-mail and phone information for pertinent healthcare provider(s) and hospital(s), along with employee's signature and a witness signature. A review of the PSEBA application will not occur until the PSEBA medical authorization release is submitted.
(D) General Information Release Required: A signed PSEBA general information release authorizing the collection of general information related to the incident, including, but not limited to, disability pension proceedings, worker's compensation records and medical records, must be submitted with the application. The PSEBA general information release must specify the name and signature of the employee along with the name and signature of a witness authorizing the collection of information pertinent to the incident review process. A review of the PSEBA application will not occur until the PSEBA general information release is submitted.
(E) Other Information: The Police Chief may require other information necessary to make a determination as to whether an administrative hearing is required, including, but not limited to, health insurance benefits the employee is currently receiving or is eligible to receive; or, any other health insurance benefits the employee or family members are otherwise entitled. The applicant has an ongoing obligation to update information provided. Failure to do so may result in the denial of benefits. (Ord. 17-3, 2-23-2017)