Application For A Disability Allowance Page 9
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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
HUMAN RESOURCE STATEMENT FOR DISABILITY ALLOWANCE
Date:
________________________________
From:
____________________________________________________________________________________
Name of Applicant
Social Security Number
Employer
To:
____________________________________________________________________________________
Name of Human Resource Director
I am applying to the Connecticut Teachers’ Retirement Board for Disability. I authorize you to submit a
statement to Connecticut Teachers’ Retirement Board. This statement should include background
information such as days missed from school, any pending workers’ compensation claims, any short or
long term disability insurance claims.
___________________________________________________________________________________________________
Applicant’s Signature
Date
HUMAN RESOURCE DIRECTOR: (
PLEASE PROVIDE THE FOLLOWING INFORMATION)
1. Please provide the attendance records of the applicant for the past 24 months;
2. Is the applicant able to perform the essential functions of their assigned position?
Yes
No
If no, please provide a list of the essential functions they are unable to perform
3. Is the applicant receiving workers’ compensation benefits?
Yes
No
4. Is the applicant receiving any board provided short or long term disability?
Yes
No
Signature of Human Resource Director
Date
TO Human Resource Director:
Please complete this form and mail or FAX directly to this office. You may add additional pages as
necessary. Please do not write on the back of this form or on the back of any additional forms.
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