A. Application For PSEBA Benefits: The Village shall maintain a PSEBA benefit application form which shall be the standard form required for a PSEBA benefit applicant (hereinafter the "applicant") to request benefits under PSEBA. The form shall be completed pursuant to the instructions on the application and delivered to the Village Administrator for review and consideration. The applicant shall provide, along with the application and the required information therein, any medical records regarding the injury, any decisions by a governing Public Safety Pension Board and supporting documentation related to such Pension Board decisions, and any additional pertinent documentation that the applicant wants to have considered or that is requested by the Village.
The PSEBA benefit application form must be signed, sworn and notarized to certify the truthfulness of the content of the information contained in the completed application. The application shall also include a PSEBA medical authorization release and a PSEBA general information release, executed and notarized by the applicant. Both the PSEBA medical release and the PSEBA general information release authorize the collection of information related to the incident that qualifies the applicant for benefits under PSEBA, including, but not limited to, the disability pension proceedings, workers' compensation records and medical records. The Village Administrator's review of the PSEBA benefit application will not occur until the application is complete including the completion of the PSEBA medical authorization release and a PSEBA general information release.
Applicant must file a complete and executed PSEBA benefit application no later than thirty (30) days from the date of the governing Safety Pension Board's granting of a line-of- duty disability pension or within thirty (30) days of the date of the adoption of this chapter, whichever is later. Failure to timely file a full and complete application will result in the forfeiture of benefits under PSEBA.
B. Application Review Process:
1. When the Village Administrator receives a complete and executed application, the Village Administrator shall review the application and engage in such additional fact-finding and/or investigation as may be deemed necessary or appropriate to evaluate the application, including, but not limited to the review of Public Safety Pension Board hearing transcripts and decisions, workers' compensation documentation, and independent medical examinations. If additional fact-finding and/or investigation is determined to be necessary, applicant shall fully cooperate. If applicant refuses or otherwise fails to fully cooperate, then the application for PSEBA benefits shall be deemed withdrawn.
2. If additional fact-finding and/or investigation set forth above is determined to be necessary by the Village Administrator, the applicant shall fully cooperate. If the applicant refuses or otherwise fails to fully cooperate, then a written notice shall be sent to the applicant reiterating the duty of full cooperation in the fact-finding and/or investigation process. If the applicant fails to cooperate as requested within twenty one (21) calendar days after service of such notice, then the application for PSEBA benefits shall be deemed withdrawn.
3. a. The Village Administrator shall make an initial determination, with a copy to applicant, within forty five (45) calendar days after the later of the following:
(1) The submission of all documentation relevant to the application; or
(2) The completion of such additional fact-finding or investigation as deemed necessary or appropriate by the Village Administrator (as stated in subsection B2 of this section).
b. The Village Administrator's written determination may include:
(1) Applicant is ineligible for benefits under PSEBA and application is denied;
(2) Applicant is eligible for benefits under PSEBA; or
(3) A hearing as set forth in subsection 1-10-3C of this chapter should be convened in order to determine whether or not applicant is eligible for benefits under PSEBA.
4. If the Village Administrator denies benefits under PSEBA based on the preliminary record, the applicant shall have the right to request a hearing, as set forth in section 1-10-3 of this chapter, by submitting a written request for such hearing to the Village Administrator within thirty (30) calendar days from the date of the Village Administrator initial determination. (Ord. O-19-18, 7-9-2018)