Application For A Disability Allowance
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12CT TEACHERS’ RETIREMENT BOARD
765 ASYLUM AVENUE HARTFORD, CT 06105-2822
“An Affirmative Action/Equal Opportunity Employer”
Toll-Free 1-800-504-1102
(860) 241-8416
Fax (860) 622-2848
APPLICATION FOR A DISABILITY ALLOWANCE
ELIGIBILITY REQUIREMENTS
▪
You cannot perform the duties of your assigned job, due to a physical or mental impairment.
▪
You are ACTIVE with your last employing Connecticut board of education, including up to ten
months of a current leave of absence where mandatory contributions were remitted; purchased
prior Connecticut teaching service previously withdrawn, and time while out on workers
compensation provided the mandatory contributions were remitted.
▪
You have five years of credited service in the public schools of Connecticut, for a non-service
related claim.
▪
You are not eligible to receive normal benefits. (35 years service, at least 25 years are CT
service, or 20 years of CT service at age 60).
FILING REQUIREMENTS
The following items must be received before your claim will be placed on the Medical Review
Committee agenda:
1) Medical Reports and office notes from your physician(s)
2) Statement from Human Resources regarding work performance and attendance records
3) Handwritten statement from you outlining the effect your illness has on your ability to perform your
job duties.
Your completed application for a disability allowance is due in this office prior to the effective
date of your disability allowance.
4) Application for a Disability Allowance
5) Beneficiary Designation Form.
6) Birth Certificate (Photocopy acceptable).
ELECTION OF SUPPLEMENTAL and/or VOLUNTARY ACCOUNTS
Members who were employed prior to June 1989 may have a 1% Supplemental account. Those members who
paid additional monies into the system have a Voluntary Account. Your choices for distribution are:
■
Refund/Rollover. Funds may be refunded directly to you, in which case, any pre-tax contributions and interest
will become taxable. Alternatively, pre-tax contributions and interest may be rolled over into another “qualified
plan”, such as an IRA. The paperwork for the refund/rollover option will be mailed to you after the effective
date of your disability allowance. Failure to return the paperwork for the refund/rollover option on a timely
basis will result in your funds being refunded directly to you which may result in federal or state tax liabilities
and related penalties.
■
Extra Annuity. In lieu of receiving your 1% Supplemental and/or Voluntary account in a lump sum, you may
elect to increase your monthly payment with an additional fixed annuity based on your account balance and
age annuity rates in effect at the time of your disability effective date. These fixed payments are excluded
from cost of living increases. Funds to be used for the purchase of an extra annuity must be received by the
Teachers’ Retirement Board no later than the effective date of your disability allowance.
DisabilityApplication Rev 4/2013
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