Form PERS-BSD-369-D "Disability Retirement Election Application" - California

What Is Form PERS-BSD-369-D?

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 November 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-369-D 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-369-D "Disability Retirement Election Application" - California

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Disability Retirement Election Application
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
For detailed instructions on how to complete this form, please refer to the publication Disability Retirement Election
Application (PUB 35).
Application Type
Disability Retirement
Industrial Disability Retirement
c
c
Service Pending Disability Retirement
Service Pending Industrial Disability Retirement
c
c
Information About You
Section 1
Please provide your
Your Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
name as it appears on
your Social Security card.
Address
City
State
ZIP
Country
(
)
(
)
Birth Date (mm/dd/yyyy)
Daytime Phone
Alternate Phone
Email Address
Information About Your Retirement
Section 2
Please enter the last day
Last Day on Payroll (mm/dd/yyyy)
Your Retirement Date (mm/dd/yyyy)
you were on payroll with a
CalPERS-covered employer.
Employer Full Name
Full Position Title
Other California Public Retirement Systems
If you are a member of a defined benefit plan with a California public retirement system other than CalPERS,
please complete the following:
Name of Reciprocal System
Last Day of Employment With Reciprocal System (mm/dd/yyyy)
Retirement Date With Reciprocal System (mm/dd/yyyy)
PERS-BSD-369-D (12/20)
Page 1 of 12
Disability Retirement Election Application
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
For detailed instructions on how to complete this form, please refer to the publication Disability Retirement Election
Application (PUB 35).
Application Type
Disability Retirement
Industrial Disability Retirement
c
c
Service Pending Disability Retirement
Service Pending Industrial Disability Retirement
c
c
Information About You
Section 1
Please provide your
Your Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
name as it appears on
your Social Security card.
Address
City
State
ZIP
Country
(
)
(
)
Birth Date (mm/dd/yyyy)
Daytime Phone
Alternate Phone
Email Address
Information About Your Retirement
Section 2
Please enter the last day
Last Day on Payroll (mm/dd/yyyy)
Your Retirement Date (mm/dd/yyyy)
you were on payroll with a
CalPERS-covered employer.
Employer Full Name
Full Position Title
Other California Public Retirement Systems
If you are a member of a defined benefit plan with a California public retirement system other than CalPERS,
please complete the following:
Name of Reciprocal System
Last Day of Employment With Reciprocal System (mm/dd/yyyy)
Retirement Date With Reciprocal System (mm/dd/yyyy)
PERS-BSD-369-D (12/20)
Page 1 of 12
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page.
Disability Information
Section 3
What is your specific disability?
Please complete all the
questions. If you need
additional space, attach
separate sheets and
be sure to include
When did the disability occur? (mm/dd/yyyy)
your name and Social
Security number or
How did the disability occur?
CalPERS ID on all sheets.
What are your limitations/preclusions due to your injury or illness?
How has your injury or illness affected your ability to perform your job?
Are you currently working in any capacity?
No
Yes
c
c
If yes, what is your employment status?
Full time
Part time
c
c
Job duties:
Other information you would like to provide:
If you indicated a third-
party liability, CalPERS
will require additional
Did a third party cause your injury?
No
Yes (If yes, CalPERS has a potential “right of subrogation.”)
c
c
information.
Treating Physician Detail
Section 4
What is the complete name and address of your treating physician(s)?
If you need additional
space, attach separate
sheets and be sure to
First Name
Last Name
Your Medical Record Number
include your name and
Social Security number or
Address
CalPERS ID on all sheets.
City
State
ZIP
Country
(
)
Specialty
Secondary Specialty
Phone Number
PERS-BSD-369-D (12/20)
Page 2 of 12
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page.
Select Your Retirement Payment Option
Section 5
Choose one of the following retirement payment options.
Your retirement payment
Unmodified Allowance
There is no beneficiary designation with this option. Skip to Section 7.
c
option choice becomes
Return of Remaining
Complete your beneficiary designation in Section 6c.
c
irrevocable 30 days
Contributions Option 1
from the date your first
retirement check is issued
100 Percent Beneficiary Option 2
c
Complete your beneficiary designation in Sections 6a and 6c.
unless you have a future
100 Percent Beneficiary Option 2
c
Complete your beneficiary designation in Section 6a.
qualifying event, such as
with Benefit Allowance Increase
the death of a beneficiary.
50 Percent Beneficiary Option 3
Complete your beneficiary designation in Sections 6a and 6c.
c
50 Percent Beneficiary Option 3
Complete your beneficiary designation in Section 6a.
c
with Benefit Allowance Increase
Flexible Beneficiary Option 4
c
Choose one of the options below.
Specific Percentage
Complete your beneficiary designation in Section 6b.
c
Specific Dollar Amount
Complete your beneficiary designation in Section 6b.
c
Court-Ordered Community
Provide your former spouse/partner’s information and choose
c
one of the options below for your share of the benefit.
Property Option 4
If you are required by a
court order to designate
your nonmember spouse
Former Spouse/Former Registered Domestic Partner (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
or partner for an ongoing
monthly benefit, choose
Unmodified Allowance
There is no beneficiary designation with this option. Skip to Section 7.
c
one of the Court-Ordered
Return of Remaining
Community Property
Complete your beneficiary designation in Section 6c.
c
Contributions Option 1
Option 4 options for your
share of the benefit.
Specific Percentage
Complete your beneficiary designation in Section 6b.
c
Specific Dollar Amount
Complete your beneficiary designation in Section 6b.
c
Complete Your Beneficiary Information – Ongoing Monthly Benefit
Section 6a
If you chose one of the following options, name one beneficiary to receive the ongoing monthly benefit
The beneficiary you name
upon your death.
in this section becomes
irrevocable 30 days
100 Percent Beneficiary Option 2
from the date your first
100 Percent Beneficiary Option 2 with Benefit Allowance Increase
retirement check is issued
50 Percent Beneficiary Option 3
unless you have a future
50 Percent Beneficiary Option 3 with Benefit Allowance Increase
qualifying event, such as
the death of a beneficiary.
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Male
Female
Nonbinary
c
c
c
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Address
City
State
ZIP
Country
PERS-BSD-369-D (12/20)
Page 3 of 12
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page.
Complete Your Beneficiary Information – Specific Percentage or
Section 6b
Specific Dollar Amount
If you chose one of the following options, name one or more beneficiaries to receive a specific percentage
Any beneficiary you name
or dollar amount of your Unmodified Allowance upon your death.
in this section becomes
irrevocable 30 days
Flexible Beneficiary Option 4/Specific Percentage or Specific Dollar Amount
from the date your first
Court-Ordered Community Property Option 4/Specific Percentage or Specific Dollar Amount
retirement check is issued
unless you have a future
qualifying event, such as
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
the death of a beneficiary.
c
Male
c
Female
c
Nonbinary
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Complete all fields for each
$
%
beneficiary and specify the
Dollar Amount
Percent of Benefit
percentage or dollar
amount. If you name more
Address
than one beneficiary and
you want your beneficiaries
City
State
ZIP
Country
to receive an equal share
of your benefits, do not
specify a dollar or
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
percentage of benefit.
c
Male
c
Female
c
Nonbinary
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
$
%
Dollar Amount
Percent of Benefit
Address
City
State
ZIP
Country
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Male
Female
Nonbinary
c
c
c
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
$
%
Dollar Amount
Percent of Benefit
Address
City
State
ZIP
Country
If you want to name more
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
than four beneficiaries, call
us toll free at 888 CalPERS
Male
Female
Nonbinary
c
c
c
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
(or 888-225-7377).
$
%
Dollar Amount
Percent of Benefit
Address
City
State
ZIP
Country
PERS-BSD-369-D (12/20)
Page 4 of 12
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page.
Complete Your Beneficiary Information – Return of Remaining Contributions
Section 6c
If you chose one of the following options, name one or more beneficiaries to receive a return of any
of your remaining member contributions. You can change this beneficiary designation at any time.
Return of Remaining Contributions Option 1
100 Percent Beneficiary Option 2
50 Percent Beneficiary Option 3
Court-Ordered Community Property Option 4/Return of Remaining Contributions Option 1
If you name more than
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
one beneficiary and you
want your beneficiaries to
Primary
Secondary
%
c
c
Birth Date (mm/dd/yyyy)
Relationship to You
Priority
Percent of Benefit
receive an equal share of
your benefits, do not
Address
specify a percentage
of benefit.
City
State
ZIP
Country
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Primary
Secondary
%
c
c
Birth Date (mm/dd/yyyy)
Relationship to You
Priority
Percent of Benefit
Address
City
State
ZIP
Country
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
c
Primary
c
Secondary
%
Birth Date (mm/dd/yyyy)
Relationship to You
Priority
Percent of Benefit
Address
City
State
ZIP
Country
If you want to name more
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
than four beneficiaries, call
us toll free at 888 CalPERS
%
c
Primary
c
Secondary
Birth Date (mm/dd/yyyy)
Relationship to You
Priority
Percent of Benefit
(or 888-225-7377).
Address
City
State
ZIP
Country
PERS-BSD-369-D (12/20)
Page 5 of 12
Page of 13