Disability Retirement Kits
Disability Retirement Kits
Mail completed Disability Applications to NYCERS at 30-30 47th Ave., Suite 1010, Long Island City, NY 11101. Mail Medical forms 605, 606, 607, 608, 609 and 613 to NYCERS’ Medical Division at 335 Adams Street, Suite 2300, Brooklyn, NY 11201. All forms can be brought to our Customer Service Center at 340 Jay Street in downtown Brooklyn.
Application for Disability Retirement – Tier 6 63/10 and Special Plan Members
Form #624
This application is for Tier 6 63/10 and Special Plan members who are applying for Disability Retirement.
Application for Disability Retirement – 22-Year Plan Members
Form #625
This application is for 22-Year Plan members who are applying for Disability Retirement.
Application for Disability Retirement – Tier 4
Form #604
Use this application if you are a Tier 4 member and wish to collect a retirement benefit due to disability.
Application for Disability Retirement – Tier 3 Uniformed Correction Force Only
Form #603
This application is for Tier 3 Correction members who wish to apply for Disability Retirement.
Application for Disability Retirement – Tier 2
Form #602
Use this application if you are a Tier 2 member and wish to collect a retirement benefit due to disability.
Application for Disability Retirement – Tier 1
Form #601
Use this application if you are a Tier 1 member and wish to collect a retirement benefit due to disability.
Enhanced Disability Benefit Election – Sanitation 22-Year Plan
Form #195
For members of the Uniformed Sanitation Force 22-Year Plan (SA-22) who wished to elect the Enhanced Disability Benefit (EDB) program. The deadline to file this election was February 28, 2017. Sanitation Force members who become participants in the SA-22 Plan on or after September 1, 2016 are automatically enrolled in the SA-22 EDB.
Enhanced Disability Benefit Election – 22-Year Plan Uniformed Correction Force Members
Form #194
For members of the Uniformed Correction Force 22-Year Plan (CF-22) who wish to elect the Enhanced Disability Benefit (EDB) program. This form must be filed with NYCERS no later than June 30, 2017. (Correction Force members who become participants in the CF-22 Plan on or after January 1, 2017 will automatically be enrolled in the CF-22 EDB and do not need to file this form.)
Physician’s Report of Disability
Form #606
This form contains your physician’s medical report and your authorization to provide information to NYCERS’ Medical Board.
Agency Report on Accident
Form #607
This form must be completed by your employer.
Applicant’s Report of Personal Disability
Form #605
This form must be filed along with your application for disability retirement benefit.
WTC Agency Report
Form #623
This form is to be completed by the agency whose employee (or former employee) has filed a Notice of Participation with NYCERS indicating that he/she participated in WTC Rescue, Recovery or Clean-Up Operations during certain qualifying periods between September 11, 2001 and September 12, 2002.
Consent of Disability Retiree to Report Personal Service Income Each Year
Form #618
By filing this form, you consent to report your annual income to NYCERS while a disability pensioner.
Earnings Limitations for Service Retirees and Disability Retirees
Brochure #958
This brochure describes the earnings limitations that service and disability retirees may be subject to if they decide to return to public service within New York City or New York State.
Disability Retirement – Tier 3 and Tier 4
Brochure #922
The disability retirement process for Tier 3 and 4 members.
Disability Retirement – Tier 1 and Tier 2
Brochure #921
The disability retirement process for Tier 1 and 2 members.
Waiver Pursuant to the Provisions of Article 14 of the Retirement and Social Security Law (RSSL) as it Pertains to Disability Retirements
Form #614
File this form with NYCERS if you want to waive the benefits of any statutory presumption relating to the cause of disability or eligibility for disability benefits
Final Medical Review Waiver (To be completed by the Member)
From #613
This form is for applicants for disability retirement benefit who want to waive the process by which a member can contest the findings of NYCERS’ Medical Board denying his or her disability claim
Affidavit Electing to Process Disability Retirement – Tier 4 Members with Tier 3 Rights
Form #611
For Tier 4 members with Tier 3 rights who wish to file for disability under the provisions of Article 14 of the RSSL
Sanitation 22-Year Plan Enhanced Disability Benefit
Fact Sheet #728
The benefits and obligations of the Enhanced Disability Benefit program (EDB) available to participants in the Uniformed Sanitation Force 22-Year Plan (SA-22 Plan).
Correction 22-Year Plan Enhanced Disability Benefit
Fact Sheet #731
The benefits and obligations of the Enhanced Disability Benefit program (EDB) available to participants in the Uniformed Correction Force 22-Year Plan (CF-22 Plan).
WTC Disability Law
Fact Sheet #703
Questions and answers about the World Trade Center Disability Law.
A Notice of Participation in WTC Rescue, Recovery, or Clean-Up Operations (NYCERS Form #622) must be filed no later than September 11, 2018.
WTC Notice of Participation
Form #622
This Notice is for any active, vested or retired member (retired after 9/11/01) who participated in World Trade Center (WTC) Rescue, Recovery or Clean-up Operations between September 11, 2001 and September 12, 2002. This form must be filed with NYCERS no later than September 11, 2018.
Withdrawal of Disability Retirement Application
Form #619
If you previously filed for Disability Retirement and you now wish to withdraw that application, please complete this form in its entirety and return it to NYCERS.
Questionnaire – Applicants for Disability Retirement
Form #609
This application is to accompany your application for Disability Retirement.
General Authorization for Medical Information
Form #608
This form authorizes NYCERS to obtain medical information pertaining to those filing for disability.