Application For A Disability Allowance Page 3
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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 x8408
(860) 241-8416
Fax (860) 622-2848
APPLICATION FOR A DISABILITY ALLOWANCE
MEMBER INFORMATION:
Name of Applicant:
Date of Birth:
Social Security #:
Street Address:
City
State/zip:
Home Phone #:
Other Phone #:
Email address:
ELECTION OF SUPPLEMENTAL and/or VOLUNTARY ACCOUNTS
Check one category for each Account you have. If in doubt, refer to your annual statement.
Account Type
Refund/Rollover*
Extra Annuity
1% Supplemental
Voluntary
* If you elect the lump sum option, additional information will be sent to you regarding the distribution of the
account(s).
LIST ALL PHYSICIANS WHO WILL BE PROVIDING MEDICAL REPORTS TO TRB. ALL REPORTS MUST BE RECEIVED
BEFORE YOUR CASE WILL BE REVIEWED.
Physician’s name
Address
Telephone
Under current laws and regulations, Medical insurance is available with your last employing Board of
Education until you are enrolled in Medicare A and B, at which time supplemental insurance is
available through Teachers’ Retirement.
Certification Statement:
I understand I am required to report all earned income, Social Security and Worker’s Compensation
Benefits to the Teachers’ Retirement Board and submit periodic medical reports when requested and
that failure to comply will result in discontinuance of my disability allowance.
Applicant’s Signature
Date
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