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Click ‘Get Form’ to open it in the editor.
Begin by filling out your personal information in the 'INFORMATION ABOUT YOU' section. Ensure you check off the benefits you are applying for, such as 'Inmate related or HIV' or 'Heart Related'.
Provide your name, sex, address, social security number, registration number, and date of birth accurately. This information is crucial for processing your application.
Complete the telephone numbers section with your work, home, and cell numbers. This allows for easy communication regarding your application.
Indicate your payroll title and employer details. Specify your length of service in years and months.
Answer questions about your payroll status and tax classification. If applicable, provide details about any medical conditions that contribute to your disability claim.
List any hospitalizations and treatments received from doctors relevant to your condition. Use additional sheets if necessary.
Finally, ensure you sign the application on the reverse side before submitting it as instructed.

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Versions	Form popularity	Fillable & printable
2022	4.2 Satisfied (40 Votes)
2018	4.7 Satisfied (88 Votes)
2013	4.1 Satisfied (26 Votes)

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