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

This version of the form is not currently in use and is provided for reference only.
Download this version of Form PERS-BSD-369-D for the current year.

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 July 1, 2017;
  • 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 printable 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).
Employer Information
F
Check if this is an employer-originated application.
Employer must fill out and sign Section 14 on the last page of this application.
Application Type
F
F
Disability Retirement
Industrial Disability Retirement
F
F
Service Pending Disability Retirement
Service Pending Industrial Disability Retirement
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
(
)
(
)
F
F
Male
Female
Birth Date (mm/dd/yyyy)
Gender
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 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 (7/17)
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).
Employer Information
F
Check if this is an employer-originated application.
Employer must fill out and sign Section 14 on the last page of this application.
Application Type
F
F
Disability Retirement
Industrial Disability Retirement
F
F
Service Pending Disability Retirement
Service Pending Industrial Disability Retirement
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
(
)
(
)
F
F
Male
Female
Birth Date (mm/dd/yyyy)
Gender
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 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 (7/17)
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?
F
F
Are you currently working in any capacity?
No
Yes
F
F
If yes, what is your employment status?
Full time
Part time
Job duties:
Other information you would like to provide:
If you indicated a third-
party liability, CalPERS
will require additional
F
F
Did a third party cause your injury?
No
Yes (If yes, CalPERS has a potential “right of subrogation.”)
information.
Treating Physician Detail
Section 4
What is the complete name and address of your treating physician(s)?
First Name
Last Name
Your Medical Record Number
Address
City
State
ZIP
Country
(
)
Specialty
Secondary Specialty
Phone Number
PERS-BSD-369-D (7/17)
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.
F
Your retirement payment
Unmodified Allowance
There is no beneficiary designation with this option. Skip to Section 7.
option choice becomes
F
Return of Remaining
Complete your beneficiary designation in Section 6c.
irrevocable 30 days
Contributions Option 1
from the date your first
retirement check is issued
F
100 Percent Beneficiary Option 2
Complete your beneficiary designation in Section 6a.
unless you have a future
with Benefit Allowance Increase
qualifying event, such as
F
100 Percent Beneficiary Option 2
Complete your beneficiary designation in Section 6a and 6c.
the death of a beneficiary or
a change in marital status.
F
50 Percent Beneficiary Option 3
Complete your beneficiary designation in Section 6a.
with Benefit Allowance Increase
F
50 Percent Beneficiary Option 3
Complete your beneficiary designation in Section 6a and 6c.
F
Flexible Beneficiary Option 4
Choose one of the options below.
F
Specific Percentage
Complete your beneficiary designation in Section 6b.
F
Specific Dollar Amount
Complete your beneficiary designation in Section 6b.
F
Court-Ordered Community
Provide your former spouse/partner’s information and choose
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
F
Unmodified Allowance
There is no beneficiary designation with this option. Skip to Section 7.
one of the Court-Ordered
F
Community Property
Return of Remaining
Complete your beneficiary designation in Section 6c.
Contributions Option 1
Option 4 options for your
share of the benefit.
F
Specific Percentage
Complete your beneficiary designation in Section 6b.
F
Specific Dollar Amount
Complete your beneficiary designation in Section 6b.
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 with Benefit Allowance Increase
from the date your first
100 Percent Beneficiary Option 2
retirement check is issued
50 Percent Beneficiary Option 3 with Benefit Allowance Increase
unless you have a future
50 Percent Beneficiary Option 3
qualifying event, such as
the death of a beneficiary or
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
a change in marital status.
F
F
Male
Female
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Address
City
State
ZIP
Country
PERS-BSD-369-D (7/17)
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
Any beneficiary you name
in this section becomes
If you chose one of the following options, name one or more beneficiaries to receive a specific percentage
irrevocable 30 days
or dollar amount of your Unmodified Allowance upon your death.
from the date your first
Flexible Beneficiary Option 4/Specific Percentage or Specific Dollar Amount
retirement check is issued
Court-Ordered Community Property Option 4/Specific Percentage or Specific Dollar Amount
unless you have a future
qualifying event, such as
the death of a beneficiary or
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
a change in marital status.
F
F
Male
Female
$
%
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar Amount
Percent of Benefit
Complete all fields for each
beneficiary and specify the
Address
percentage or dollar
amount. If you name more
City
State
ZIP
Country
than one beneficiary and
you want your beneficiaries
to receive an equal share
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
of your benefits, do not
F
F
Male
Female
$
%
specify a dollar or
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar Amount
Percent of Benefit
percentage of benefit.
Address
City
State
ZIP
Country
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
F
F
Male
Female
$
%
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
F
F
Male
Female
$
%
us toll free at 888 CalPERS
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar Amount
Percent of Benefit
(or 888-225-7377).
Address
City
State
ZIP
Country
PERS-BSD-369-D (7/17)
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 name more than
If you chose one of the following options, name one or more beneficiaries to receive a return of any
one beneficiary and you
of your remaining member contributions. You can change this beneficiary designation at any time.
want your beneficiaries to
Return of Remaining Contributions Option 1
receive an equal share of
100 Percent Beneficiary Option 2
your benefits, do not
50 Percent Beneficiary Option 3
specify a percentage
Court-Ordered Community Property Option 4/Return of Remaining Contributions Option 1
of benefit.
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
F
F
F
F
Male
Female
Primary
Secondary
%
Birth Date (mm/dd/yyyy)
Gender
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
F
F
F
F
Male
Female
Primary
Secondary
%
Birth Date (mm/dd/yyyy)
Gender
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
F
F
F
F
%
Male
Female
Primary
Secondary
Birth Date (mm/dd/yyyy)
Gender
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
F
F
F
F
%
us toll free at 888 CalPERS
Male
Female
Primary
Secondary
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Priority
Percent of Benefit
(or 888-225-7377).
Address
City
State
ZIP
Country
PERS-BSD-369-D (7/17)
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