A. Employees, or family member(s) of injured or deceased employees, who may qualify for PSEBA benefits (hereinafter "applicant") must file a full and complete application in writing with the Village Manager no later than sixty (60) calendar days from the date of issuance of a written decision by the Police Pension Fund Board or Firefighter Pension Fund Board, whichever is applicable, granting a line of duty disability pension. Failure to timely file a full and complete application shall result in a forfeiture of benefits under PSEBA.
B. A complete application shall include the following:
1. The applicant's name and date of hire, detailed information regarding the incident for which PSEBA benefits are sought, including information relating to how the injury was sustained in the line of duty, including the date, time, place, nature of injury, and other factual circumstances surrounding the incident.
2. The applicant's firsthand knowledge explaining, to the Village's satisfaction, how the injury directly resulted from:
a. Response to fresh pursuit;
b. Response to what is reasonably believed to be an emergency;
c. Response to an unlawful act perpetrated by another; or
d. The investigation of a criminal act.
3. A signed unconditional PSEBA medical authorization release which authorizes the Village to collect information related to the incident including, but not limited to, disability pension proceedings, worker's compensation records, and medical records, and a complete list of the names and addresses for all health care providers involved in the diagnosis, treatment, review or handling of the injury for which PSEBA benefits are sought.
4. A signed unconditional PSEBA general information release specifying the name and signature of the applicant or her/his authorized representative along with legal proof of said representation and name and signature of witness authorizing the collection of information necessary to review the application.
5. The names, addresses and telephone numbers of witnesses to the incident resulting in the injury for which PSEBA benefits are sought, along with any statements of the witnesses which the applicant either possesses, may obtain or is aware of.
6. The names, addresses and telephone numbers of witnesses the applicant intends to call at the PSEBA hearing, along with their anticipated subjects of testimony and any opinions the witnesses are expected to give.
7. Information and documentation filed with the appropriate Pension Board.
8. Information regarding other sources of health insurance benefits currently enrolled in, received by, or available to the applicant and/or the applicant's family members, including the source of the benefits and the benefits provided or available.
9. Any other information supporting the PSEBA eligibility requirements.
C. The PSEBA application must be sworn to by the applicant and notarized to certify the truthfulness of the application's contents. A review of the application shall not occur until the application is complete.
D. On the date that the PSEBA application is deemed complete by the Village, the completed application shall then be submitted to the Village Manager as the preliminary record, and a copy of the same shall be date stamped and provided to the applicant.
E. Upon receipt of a complete application for PSEBA benefits, the Village Manager shall set the matter for an administrative hearing with the Village Manager or his or her designee serving as the Hearing Officer to make a determination on whether to grant the application and provide the applicant with benefits under PSEBA.
F. The applicant shall be given written notice of the date for the administrative hearing not less than ten (10) calendar 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 (7) calendar days after being served. The Hearing Officer shall establish an alternative hearing date within thirty (30) calendar days of the original hearing date. The applicant's failure to appear at the administrative hearing shall result in denial of PSEBA benefits.
G. The Village Manager may delegate any of his/her authority, duties and obligations under this chapter, in whole or part, to a designee, or designees. (Ord. 18-2922, 5-21-2018)