Disability / Retirement Benefits Forms

Here are the forms necessary to qualify for disability leave and/or disability retirement benefits. For detailed information, review these instructions.

• Complete Form 1: Fill in all information requested, sign and date the form.

• Ask your physician or health care provider to complete Form 3, sign and date the form. (A medical report letter in place of Form 3 is allowed.)

• Submit both Form 1 and Form 3 to your LEOFF-1 employer in time to meet the deadline for submission to the Board. All completed claims need to be received in the Board office by the second Wednesday of the month in which you wish them reviewed.
  
• Form 1 / Form 1 (fill-in). Application for LEOFF-1 Disability-Retirement Benefits (to be completed by LEOFF-1 employee/applicant)
  
• Form 2 / Form 2 (fill-in). Application for LEOFF-1 Disability-Retirement Benefits continuation (to be completed by member's employer)
  
• Form 3 / Form 3 (fill-in). Statement of Physician-Provider Treating Employee (to be completed by member's physician/health care provider)
  
• Form 4 / Form 4 (fill-in). Waiver of Disability Leave (to be completed by LEOFF-1 employee/applicant)

For further information contact:
Curt Nakata, Board Administrator, KCLEOFF1
The Chinook Building, CNK-ES-0240
401 Fifth Avenue
Seattle, WA 98104-2333
Phone: 206-263-6394, or 206-684-1556 (call center)
Fax: 206-296-7679
8 a.m.-noon, Monday-Friday

Updated: Apr. 30, 2008