Form PERS-BSD-TDA "Employer Originated Disability Allowance Estimate Request" - California

What Is Form PERS-BSD-TDA?

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:

  • The latest edition provided by the California Public Employees' Retirement System;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PERS-BSD-TDA 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-TDA "Employer Originated Disability Allowance Estimate Request" - California

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Employer Originated Disability Allowance Estimate Request
888 CalPERS (or 888-225-7377)
• TTY: (877) 249-7442
• FAX: (916) 795-0701
This is not an application for retirement. This is to be used by the State employer only when the employer will be
generating a disability application on behalf of the member. This is a request for an estimate of potential future
retirement benefit amounts to determine the amount of Temporary Disability Allowance. See the back of this form for
instructions.
Section 1
Information About the Member
Nam e of Member (First Name, Middle Initial, Last Name)
Mem ber’s Social Security Number or CalPERS ID
(
)
(
)
We will mail the
Employer Work Phone
Employer Fax Number
Me mber’s Birth Date (mm/dd/yyyy)
estimate to th
e
employer's address you
provide on the form.
Em ployer Address
ZIP
Cit y
S tate
Retirement Information
Section 2
Type of estimate:
 Disability Retirement
 Industrial Disability Retirement
Member's Last Day on Pay:
Date Required (mm/dd/yyyy)
Will the member be married or in a registered domestic partnership as of the effective disability retirement
date?
 Yes
 No
Does the member have any unmarried children who are under age 18 or disabled or any unmarried children
who were disabled prior to their 18th birthday and who are still disabled?
 Yes
 No
How many beneficiaries do you want to include in the estimate?
 None
What is a survivor vs. a
 One (Complete the information in the space provided below.)
beneficiary? See the
back of this form for
details and a complete
Name of Beneficiary
Relationship to Member
Birth Date (mm/dd/yyyy)
description of the
 One or more and with a specific dollar or specific percentage amount to each beneficiary.
available retirement
payment options.
(Complete the information in the spaces provided below.)
Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy)
Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy)
Birth Date (mm/dd/yyyy)
Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy)
Dollar or Percent of Benefit
Advanced Estimate Scenarios
Section 3
If the employee is a member of another California public retirement system and he or she wants to use the
See the back of this
final compensation with the other system in the estimate, complete the information below.
form for information
regarding the
Advanced Estimate
Name of Reciprocal System
Estimated Final Compensation Amount
Scenarios.
Mail to:
CalPERS Benefit Services Division
• P.O. Box 942717, Sacramento, California 94229-2717
PERS-BSD-TDA Estimate
Page 1 of 1
Employer Originated Disability Allowance Estimate Request
888 CalPERS (or 888-225-7377)
• TTY: (877) 249-7442
• FAX: (916) 795-0701
This is not an application for retirement. This is to be used by the State employer only when the employer will be
generating a disability application on behalf of the member. This is a request for an estimate of potential future
retirement benefit amounts to determine the amount of Temporary Disability Allowance. See the back of this form for
instructions.
Section 1
Information About the Member
Nam e of Member (First Name, Middle Initial, Last Name)
Mem ber’s Social Security Number or CalPERS ID
(
)
(
)
We will mail the
Employer Work Phone
Employer Fax Number
Me mber’s Birth Date (mm/dd/yyyy)
estimate to th
e
employer's address you
provide on the form.
Em ployer Address
ZIP
Cit y
S tate
Retirement Information
Section 2
Type of estimate:
 Disability Retirement
 Industrial Disability Retirement
Member's Last Day on Pay:
Date Required (mm/dd/yyyy)
Will the member be married or in a registered domestic partnership as of the effective disability retirement
date?
 Yes
 No
Does the member have any unmarried children who are under age 18 or disabled or any unmarried children
who were disabled prior to their 18th birthday and who are still disabled?
 Yes
 No
How many beneficiaries do you want to include in the estimate?
 None
What is a survivor vs. a
 One (Complete the information in the space provided below.)
beneficiary? See the
back of this form for
details and a complete
Name of Beneficiary
Relationship to Member
Birth Date (mm/dd/yyyy)
description of the
 One or more and with a specific dollar or specific percentage amount to each beneficiary.
available retirement
payment options.
(Complete the information in the spaces provided below.)
Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy)
Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy)
Birth Date (mm/dd/yyyy)
Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy)
Dollar or Percent of Benefit
Advanced Estimate Scenarios
Section 3
If the employee is a member of another California public retirement system and he or she wants to use the
See the back of this
final compensation with the other system in the estimate, complete the information below.
form for information
regarding the
Advanced Estimate
Name of Reciprocal System
Estimated Final Compensation Amount
Scenarios.
Mail to:
CalPERS Benefit Services Division
• P.O. Box 942717, Sacramento, California 94229-2717
PERS-BSD-TDA Estimate
Page 1 of 1
Information About The Member
Section 1
Complete all fields.
Retirement Information
Section 2
Estimated Retirement Date - The estimated retirement date will be the day following the last day on payroll
indicated on this form. If no date is provided, we will use the first of the month the estimate is received.
Important! We will only provide an estimate of the Unmodified allowance if the beneficiary information is
not completed. The amount of Temporary Disability Allowance should be based on the amount of the
retirement payment option.
What is a survivor? - A survivor receives a monthly benefit regardless of the retirement payment chosen. We
only include this in the retirement estimate if the employer contracts to provide this benefit. A survivor is
defined by law as:
 a spouse or registered domestic partner who was married or registered to the member for at least one year
before his or her service retirement date and continuously until death. (For disability or industrial
disability retirement, these conditions must be met on or before the effective date of the member's
disability or industrial disability retirement.)
 natural or adopted unmarried children under age 18.
 an unmarried child who was disabled prior to age 18 and whose disability continues without interruption
until the disability ends or until marriage.
 qualifying financially dependent parents, if none of the above.
What is a beneficiary? - A beneficiary is any person the member names to receive either a one-time
lump-sum payment or ongoing monthly benefit upon his or her death.
Retirement Options - When the member retires, he or she will choose one of the following
retirement options and name a beneficiary.
 Unmodified Allowance - Provides the highest monthly allowance paid for life. There is no continuing
monthly benefit to a beneficiary and no return of unused member contributions upon the member's death.
Return of Remaining Contributions Option 1 - Provides a lump-sum payout of any remaining
member contributions in the account account to one or more beneficiaries upon the member's death.
 100 Percent Beneficiary Option 2 with Benefit Allowance Increase - Provides 100 percent of the
option portion of the member's monthly benefit to a named beneficiary upon the member's death. If
the beneficiary dies before the member, or if the member has another qualifying event, such as a
change in marital status, the member's benefit will increase to the Unmodified Allowance.
 100 Percent Beneficiary Option 2 - Provides 100 percent of the option portion of the member's
ongoing monthly benefit to a named beneficiary upon the member's death. Upon both the
member and beneficiary's deaths a lump-sum payout of any remaining member contributions in
the account will be paid to one or more named secondary beneficiaries.
 50 Percent Beneficiary Option 3 with Benefit Allowance Increase - Provides 50 percent of the
option portion of the member's ongoing monthly benefit to a named beneficiary upon the member's
death. If the beneficiary dies before the member, or the member has another qualifying event, such as
a change in marital status, his or her benefit will increase to the Unmodified Allowance.
 50 Percent Beneficiary Option 3 -Provides 50 percent of the option portion of the member's ongoing
monthly benefit to a named beneficiary upon the member's death. Upon both the member and
beneficiary's deaths, a lump-sum payout of any remaining member contributions in the account will
be paid to one or more named secondary beneficiaries.
 Flexible Beneficiary Option 4 - Provides an ongoing monthly benefit of a specific dollar amount or
percentage of the member's Unmodified Allowance to one or more named beneficiaries upon the
member's death.
Advanced Estimate Scenarios
Section 3
Reciprocity
 Enter the name of the other California public retirement system the member is a part of, if applicable.
 Enter the member's highest average annual compensation for any consecutive 12- or 36-month period
of employment with the other retirement system.
 To be eligible for full reciprocal benefits, such as final compensation exchange, the member must retire
concurrently. Refer to the When You Change Retirement Systems publication for detailed information.
PERS-BSD-TDA Estimate
Page of 2