To complete the Disability Certification, first print your name and social security number in the spaces provided at
the top of the form.
Next, take the form to the doctor treating your disability and ask him to
complete “Section I - Physician must complete”. Your doctor must complete this section in
full or it will delay your claim.
IMPORTANT: You must file a Disability Certification
with the Fund Office within 1 year from the onset of the disability
or it will be rejected as having been received too late for acceptance.
If you are also a Participant of the Laborers Pension Trust Fund
and you are receiving temporary State Disability Insurance or
Workers’ Compensation payments, the Pension Plan may grant you up to five years pension disability hours. If you are receiving
disability payments, complete Section II - Laborer must complete. Be sure to respond to each item. Pay
particular attention to item #5 which asks the dates of your first and last payments. When filling in these dates, be sure to
indicate the month, day and year. If you are still receiving payments, enter the date of the first payment and that you are
still receiving them. You may also be asked to supply copies of check stubs. (If you are not a Participant of the Pension Plan,
skip Section II.)
Read Section III - Laborer’s authorization for release of
medical information. Your signature authorizes the release of medical information and, unless you sign this section,
your claim cannot be processed.
Complete the form by signing and providing the information requested in
Section IV - Laborer must complete and sign.
Be advised that a Disability Certification is not an
application for a pension. If your disability is expected to last beyond one year, you should contact the
Fund Office for information regarding Disability Pension.
Once the Fund Office receives and processes your Disability
Certification, we will notify you of the action taken on your Disability Certification by mailing you a Notice
of Disability Hour Credit.