FORM L PARK RIDGE FIREFIGHTERS' PENSION FUND APPLICATION FOR DISABILITY BENEFITS. Member of the Fire Department for year(s), month(s), and day(s).

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1 FORM L PARK RIDGE FIREFIGHTERS' PENSION FUND APPLICATION FOR DISABILITY BENEFITS Name: Rank: Age: Date of probationary appointment: Member of the Fire Department for year(s), month(s), and day(s). I hereby make application for a disability pension from the Park Ridge Firefighters Pension Fund as of, under the Illinois Pension Code. Please indicate any time periods that would not count as creditable service under Section of the Illinois Pension Code (40 ILCS 5/4-108) (furloughs and leaves of absence with no pay exceeding thirty (30) days in any one (1) year where no required contribution was made to the Fund): Name of Spouse: Names of Natural or Adopted Children, or Dependent Parents or Dependent Adult Children (if applicable): Please specifically describe the nature of your disability/disabilities. Please include the time, date, and location of cause of disability or onset of disability: Please list any and all witnesses to your injury or illness that has given rise to your disability: I hereby apply for the following type(s) of disability pension: in the line of duty disability (40 ILCS 5/4-110) not in the line of duty disability (40 ILCS 5/4-111) occupational disease disability (40 ILCS 5/ )

2 MEDICAL TREATMENT/EVALUATION Prior to sending you for evaluation by three (3) examining physicians as required by Section of the Illinois Pension Code (40 ILCS 5/4-112), the Fund must obtain your medical records from any treating health care providers in regards to your disability. Thus, it is imperative that you provide complete and accurate information. If the medical records for a particular health care provider must be obtained from a medical records department or other off-site location, please provide that information, as well. If additional consent forms are required to be completed for that health care provider in order to release records to the Fund, please complete and attach such forms. Please list any physician or other health care provider(s) who have examined or tested you regarding this disability(s) (attach additional sheet if necessary): NAME ADDRESS/PHONE DATE(S) OF EXAMINATION Please list your personal physician(s) or other health care provider(s): NAME ADDRESS/PHONE DATE(S) OF EXAMINATION

3 What treatment(s) and/or surgery(s) have you had in regards to this disability? TREATMENT/SURGERY DATE TREATING PHYSICIAN Have you had physical therapy with regards to your disability? Yes [ ] No [ ] If yes, please list name of physical therapist, location of therapy, and dates of service. NAME ADDRESS/PHONE DATE(S) OF THERAPY Have you had a functional capacity evaluation with regards to this disability? Yes [ ] No [ ] If yes, please list the name of the facility, address, and phone number where you were tested and the date of the evaluation. NAME ADDRESS/PHONE DATE OF FCE OUTSIDE EMPLOYMENT Have you maintained employment outside the Fire Department immediately before, during or after the event(s) causing or contributing to your disability? Yes [ ] No [ ] If yes, please provide the following information on each and every outside employer (attach additional sheets, if necessary): Name of Employer: Position held: Address of Employer: Phone Number: Fax Number: Dates of Employment:

4 Description of job duties (please attach job description): Where you involved in any incident or did you suffer any injury while working in this outside employment positions that caused or contributed to your disability? Yes [ ] No [ ] If yes, please describe the incident or injury, including time, date, location, and which employer it involved: WORKER S COMPENSATION Have you filed a worker s compensation claim in connection with your current disability? Yes [ ] No [ ] If yes, please provide date(s) of filing and case number(s): Do you have an attorney representing you in your disability application? Yes [ ] No [ ] If yes, please provide the following: Attorney s Name: Address: Phone: Fax: I also hereby consent to the release of the following to the Board of Trustees of the Park Ridge Firefighters' Pension Fund and its attorneys: (1) any and all medical records prepared during the physical examination I was required to undergo for employment with the Park Ridge Fire Department or application with the Park Ridge Firefighters' Pension Fund; (2) any examination by the physician(s) or physical therapists I listed above; (3) any medical test results and any examination by any physician or physical therapist which is relevant to the application I am making; (4) any relevant employment records from the Park Ridge Fire Department or any employer I have listed above; and (5) any other additional relevant records from any source that may be relevant to this application. A photocopy of the authorization shall be as effective and valid as the original.

5 I also understand that I must complete and sign an authorization for release of health information (Form E) which is attached to this application. Social Security Number Signature of Petitioner Address Print Name City, State, and Zip Code Phone Date Date of Birth FOR BOARD USE ONLY Received by on (date) Signature The foregoing application having been duly presented and considered by the Board of Trustees of the Park Ridge Firefighters' Pension Fund, the same is hereby Approved/Rejected (circle one) this day of,. BOARD OF TRUSTEES OF THE PARK RIDGE FIREFIGHTERS' PENSION FUND By: By: President Secretary