(A) Full time law enforcement officers, or family member(s) of an injured or deceased full time law enforcement officer, (“applicant”) must file a full and complete PSEBA application in writing within 30 days of filing a pension claim with the village (the “PSEBA application”). The village shall notify applicant if the PSEBA application is incomplete and applicant shall have five days to remedy their application.
(B) A complete PSEBA application includes the following:
(1) The name of the applicant, date of hire, detailed information regarding the incident from which the claim arises (the “incident”), including information relating to how the injury was sustained in the line of duty (date, time, place, nature of injury, and other factual circumstances surrounding the incident giving rise to said claim);
(2) The applicant’s firsthand knowledge detailing how the injury/death qualifies the applicant for benefits under the Public Safety Employee Benefits Act (the “Act”);
(3) A signed and sufficient medical authorization release which authorizes the collection of information related to the incident including, but not limited to, disability pension proceedings, worker’s compensation records, and medical records and specifies the name and address for pertinent health care provider(s);
(4) A signed and sufficient general information release specifying the name and signature of the applicant or his or her authorized representative along with legal proof of said representation authorizing the collection of information pertinent to the review and analysis of the PSEBA application;
(5) The name(s) and addresses of witnesses to the incident;
(6) The name(s) and addresses of witnesses the applicant intends to call at the PSEBA hearing;
(7) Information and supporting pension documentation filed with the Police Pension Board;
(8) Information supporting the PSEBA eligibility requirements; and
(9) Other sources of health insurance benefits currently enrolled in or received by the applicant and/or family members if the applicant is deceased.
(C) The PSEBA application must be submitted to the Village Administrator.
(D) The PSEBA application must be sworn and notarized to certify the truthfulness of the content of the information. A review of the application shall not occur until the application is complete.
(E) On the date that the PSEBA application is deemed complete by the village, the completed application shall then be submitted to the village as the preliminary record, and a copy of the same shall be date stamped and provided to the applicant.
(F) Upon receipt of a complete PSEBA application , the village shall set the matter for an administrative hearing before a hearing officer to make a determination on whether to grant the applicant PSEBA benefits based on the applicable law and the evidence presented at the administrative hearing.
(G) The applicant will be given written notice of the date for the scheduled administrative hearing to
be served not less than ten days prior to the commencement of the hearing. If the applicant, upon receiving written notice of the administrative hearing, cannot attend said date, the applicant must contact the hearing officer in writing within seven days after being served. The hearing officer shall establish an alternative hearing date which is within 30 days of the original hearing date. Failure to appear at the administrative hearing shall result in denial of PSEBA benefits.
(Ord. 1925, passed 3-5-18)