A PSEBA application shall be filed by a PSEBA applicant no later than thirty (30) days from the date a permanent line-of-duty disability pension claim is awarded. Any police chief who is not subject to the jurisdiction of the Police or Fire Pension Board shall submit a completed PSEBA application within six (6) months of sustaining the alleged catastrophic injury.
The Village Administrator shall provide the applicant with a copy of this section at the time the PSEBA application is provided.
A. The application shall include the name of the employee; the full name of the applicant's spouse, date of marriage, with marriage license attached; birth certificates or adoption orders for all dependent children, and any and all other documents establishing that the child is "dependent" as set forth in the village's health insurance plan document; the date of hire; detailed information regarding the incident including date, time, place and nature of injury, and any other factual circumstances surrounding the incident giving rise to said claim; the identities of witnesses to the incident, the names of witnesses the applicant may call at a PSEBA hearing and the names and addresses of the employee's medical providers; information and supporting documentation filed with the Pension Board by the applicant and all exhibits on file with the Pension Board; any and all rulings or determinations by the Pension Board; any and all documents supporting the PSEBA eligibility requirement for applicant's beneficiaries, including: proof of active school enrollment and employment. Failure to file a fully complete application, along with submittal of all supporting documents, shall result in a forfeiture of PSEBA benefits until the next date of open enrollment for the insurance.
B. Medical Release Required: Medical records shall be secured by the village. Medical releases provided by the Village Administrator authorizing the collection of medical information by the village related to the injury incident, including, but not limited to, disability pension proceedings, worker's compensation records and medical records shall be signed by the applicant and timely submitted with the PSEBA application. The PSEBA medical release shall specify the name, address, email and phone information for all pertinent health care providers and hospitals, along with the employee's signature and a witness's signature. The release shall comply with HIPAA standards. Medical records shall be considered "supporting documents" as required above.
C. Additional Information: The Human Resources Department shall, at any time, have the authority to modify the PSEBA application, or seek additional information from an applicant, to better enable the village to ascertain the applicant's qualifications.
D. No Review Until Complete Application Filed: The village's initial review of the PSEBA application will not occur until all of the required information, including the supporting documents, are submitted to the Human Resources Department.
E. Sworn Application: Any application for PSEBA benefits shall be sworn to by the applicant and notarized. All supporting documents filed for PSEBA qualification shall be verified under oath by the applicant and notarized. (Ord. 2020-20, 9-22-2020; amd. Ord. 2022-49, 8-23-2022)