Form PERS-BSD-92 "Workers' Compensation Carrier Request" - California

What Is Form PERS-BSD-92?

This is a legal form that was released by the California Public Employees' Retirement System - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2019;
  • The latest edition provided by the California Public Employees' Retirement System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PERS-BSD-92 by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download Form PERS-BSD-92 "Workers' Compensation Carrier Request" - California

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Workers’ Compensation Carrier Request
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Fax: (916) 795-1280
Member Information
Section 1
You must complete the
If you have filed a workers’ compensation claim for the illness or injury directly related to the application for disability
or industrial disability retirement, this Workers’ Compensation Carrier Request form (reverse side) must be completed
front side of this form, sign,
by your employer’s workers’ compensation insurance carrier.
date and forward to your
workers’ compensation
insurance carrier.
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Employer Name
Claim Number 1
Date (mm/dd/yyyy)
Body Part(s)
Claim Number 2
Date (mm/dd/yyyy)
Body Part(s)
Claim Number 3
Date (mm/dd/yyyy)
Body Part(s)
Claim Number 4
Date (mm/dd/yyyy)
Body Part(s)
Authorization to Release Information
Section 2
I have submitted an application for disability or industrial disability retirement with the California Public
Send this form
Employees’ Retirement System (CalPERS). You are hereby authorized to furnish CalPERS, or its representative,
directly to your workers’
any and all information, including photocopies of records in your possession, which CalPERS requires solely to
compensation insurance
assist in determining my physical or mental condition, illness, or disability. The purpose of this authorization is
carrier. They will complete
to assist CalPERS in determining my right to retirement or reinstatement under the Retirement Law pursuant to
the reverse side of
Government Code section 20128, and no other purpose. This authorization shall be valid for four years from
this form and send the
the date shown below. A photographic copy of this authorization shall be as valid as the original.
requested information
to CalPERS.
Signature of Member
Date (mm/dd/yyyy
This form continues on the back.
PERS-BSD-92 (12/19)
Page 1 of 2
Workers’ Compensation Carrier Request
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Fax: (916) 795-1280
Member Information
Section 1
You must complete the
If you have filed a workers’ compensation claim for the illness or injury directly related to the application for disability
or industrial disability retirement, this Workers’ Compensation Carrier Request form (reverse side) must be completed
front side of this form, sign,
by your employer’s workers’ compensation insurance carrier.
date and forward to your
workers’ compensation
insurance carrier.
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Employer Name
Claim Number 1
Date (mm/dd/yyyy)
Body Part(s)
Claim Number 2
Date (mm/dd/yyyy)
Body Part(s)
Claim Number 3
Date (mm/dd/yyyy)
Body Part(s)
Claim Number 4
Date (mm/dd/yyyy)
Body Part(s)
Authorization to Release Information
Section 2
I have submitted an application for disability or industrial disability retirement with the California Public
Send this form
Employees’ Retirement System (CalPERS). You are hereby authorized to furnish CalPERS, or its representative,
directly to your workers’
any and all information, including photocopies of records in your possession, which CalPERS requires solely to
compensation insurance
assist in determining my physical or mental condition, illness, or disability. The purpose of this authorization is
carrier. They will complete
to assist CalPERS in determining my right to retirement or reinstatement under the Retirement Law pursuant to
the reverse side of
Government Code section 20128, and no other purpose. This authorization shall be valid for four years from
this form and send the
the date shown below. A photographic copy of this authorization shall be as valid as the original.
requested information
to CalPERS.
Signature of Member
Date (mm/dd/yyyy
This form continues on the back.
PERS-BSD-92 (12/19)
Page 1 of 2
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page.
To Be Completed By Workers’ Compensation Insurance Carrier
Section 3
Your help is needed in the
Claim Number 1
WCAB Number
Date of Injury (mm/dd/yyyy)
evaluation of my eligibility
No
Yes
No
Yes
for disability or industrial
c
c
c
c
Body Part(s)
Liability Accepted
Condition P&S
disability retirement.
Claim Number 2
WCAB Number
Date of Injury (mm/dd/yyyy)
Be sure to send CalPERS
a copy of all medical
c
No
c
Yes
c
No
c
Yes
Body Part(s)
Liability Accepted
Condition P&S
reports for the claim
number(s) listed.
Include job descriptions/
Claim Number 3
WCAB Number
Date of Injury (mm/dd/yyyy)
job analyses, depositions,
c
No
c
Yes
c
No
c
Yes
investigation reports,
Body Part(s)
Liability Accepted
Condition P&S
videotapes, and approved
orders from the
Claim Number 4
WCAB Number
Date of Injury (mm/dd/yyyy)
Workers’ Compensation
No
Yes
c
No
c
Yes
c
c
Appeals Board.
Body Part(s)
Liability Accepted
Condition P&S
If liability is not accepted, provide reason (Reference Claim Number)
If condition is not permanent and stationary, what is estimated time period or date? (Reference Claim Number)
Has settlement occurred?
Yes
No
c
c
If Yes,
Stipulated Award
%
Claim Number(s)
c
C & R
Claim Number(s)
c
$
F & A
%
Claim Number(s)
c
Is there a possibility of third party liability?
Yes
No
c
c
Are you in the process of, or have you completed any investigations?
Yes
No If Yes, provide copies.
c
c
Are further exams scheduled?
Yes
No
c
c
Name of Doctor
Specialty
Appointment Date
AME
QME
Treating Physician
Other
c
c
c
c
Please use additional
sheets to supply any
Name of Doctor
Specialty
Appointment Date
additional background,
AME
QME
Treating Physician
Other
information, or comments.
c
c
c
c
Signature of Workers’ Compensation Insurance Carrier
Section 4
Signature of Workers’ Compensation Representative
Date (mm/dd/yyyy)
(
)
Print Workers’ Compensation Representative’s Name
Phone Number
Mail to:
CalPERS Disability & Survivor Benefits Division
P.O. Box 2796, Sacramento, California 95812-2796
PERS-BSD-92 (12/19)
Page 2 of 2
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1.
Enrollee identification
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefits among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confidentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
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