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| Death Benefits |
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HOW TO APPLY FOR INITIAL BENEFITS
BASED ON A QUALIFYING DEATH
For all initial claims requesting benefits the following forms must be submitted to initiate the application process:
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Original M-1 (Application for Benefits) completed by applicant selecting “New Application” and all benefits being requested.
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Original M-3 (Notice of Death) completed by employer within 3 days of death.
Additionally, the following required information will assist the Board in processing your claim for each benefit requested:
LUMP SUM BENEFIT
For $25,000 (one-time) lump sum benefit, please submit the following:
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Copy of any incident reports or police reports showing date and manner of death
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Copy of death certificate, if available
MORTGAGE BENEFITS
For a one-time mortgage benefit (up to 12 months), please submit the following:
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Copy of Homeowner’s policy verifying there is no mortgage insurance on the applicant’s home.
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Copy of Mortgage Statement showing monthly mortgage amount
HEALTH AND DENTAL BENEFITS
For health and dental benefits, please submit the following:
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Copy of policy in effect at time of applicant’s death
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Verification alternative coverage is not provided
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Copy of premium showing monthly benefit amount and individuals covered under policy at time of death (NOTE: Benefits only available for qualifying spouse up to five years or until spouse remarries, whichever occurs first; and until a child or dependent attains the age of 18, or if dependent attending school, age 23)
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Federal ID # , Mailing Address and telephone number for Insurance Company (for payments made directly to insurance company). If requesting reimbursement of funds previously paid, submit verification of prior payments (e.g., cancelled checks, receipts)
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For family members who qualify due to full-time enrollment in school, submit verification of enrollment
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Duration of time benefits are requested (i.e., quarterly, annually, etc.).
SCHOLARSHIP BENEFITS
For educational benefits, please submit the following:
Standard Benefit for a Graduate Program of Higher Education:
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Verification of enrollment in graduate program
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Verification applicant has exhausted the [federal] education benefits available under 28 C.F.R., Part 32, subpart B and has made application within one year from the date of exhaustion of those benefits.
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Verification of application for other available public education benefits
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Copy of tuition costs/fees from selected college
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Duration of time benefits are requested (i.e., quarter, semester, etc.)
Alternate Benefit for an Undergraduate Program:
(Note: Apply only if ineligible to receive benefits from federal program)
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Verification of enrollment in undergraduate program
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Verification applicant was ineligible for federal education benefits available under 28 C.F.R., Part 32, subpart B.
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If applicant is a child or dependent of a public safety officer, submit verification of date applicant graduated from high school and verification applicant was a minor at the time a qualifying public safety officer suffered a qualifying death. (NOTE: Must apply within five (5) years from date of graduation)
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If applicant is a spouse of a public safety officer who suffered a qualifying death, submit verification of marriage to officer.
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Copy of tuition costs/fees from selected college
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Duration of time benefits are requested (i.e., quarter, semester, etc.)
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| Disability Benefits |
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HOW TO APPLY FOR INITIAL BENEFITS
BASED ON A QUALIFYING DISABILITY
For all initial claims requesting benefits the following forms must be submitted to initiate the application process:
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Original M-1 (Application for Benefits) completed by applicant, selecting “New Application” and all benefits being requested.
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Original M-3 (Notice of Permanent Total Disability) completed by employer within 3 days of determination of Permanent Total Disability
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Determination of Permanent Total Disability from employer’s Workers Compensation Board
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Physician Statement regarding Permanent Total Disability (see attached)
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Vocational Rehabilitation Assessment (if applicable)
Additionally, the following required information will assist the Board in processing your claim for each benefit requested:
LUMP SUM BENEFIT
For $25,000 (one-time) lump sum benefit, please submit the following:
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Copy of any incident reports or police reports showing date and manner of injury causing permanent total disability
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Copy of any medical evaluations by licensed physician showing initial evaluation and subsequent prognosis
MORTGAGE BENEFITS
For a one-time mortgage benefit (up to 12 months), please submit the following:
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Copy of Homeowner’s policy verifying there is no mortgage insurance on the applicant’s home.
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Copy of Mortgage Statement showing monthly mortgage amount
HEALTH AND DENTAL BENEFITS
For health and dental benefits, please submit the following:
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Copy of policy in effect at time of applicant’s injury
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Verification alternative coverage is not provided
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Copy of premium showing monthly benefit amount and individuals covered under policy at time of qualifying disability (NOTE: Benefits only available for up to five years for public safety officer and spouse. Benefits available for a child or dependent until the age of 18, or if attending school, age 23)
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| Supplemental Benefits |
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HOW TO APPLY FOR SUPPLEMENTAL BENEFITS
For all supplemental claims requesting benefits the following form must be submitted to initiate the request:
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Original M-1 (Application for Benefits) completed by applicant selecting “supplemental benefits” and all benefits being requested
Additionally, the following required information will assist the Board in processing your claim for each benefit requested:
HEALTH AND DENTAL BENEFITS
For health and dental benefits, please submit the following:
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Copy of premium showing monthly benefit amount and individuals covered under policy
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Duration of time benefits are requested (i.e., quarterly, annually, etc.).
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Federal ID # , Mailing Address and telephone number for Insurance Company (for payments made directly to insurance company). If requesting reimbursement of funds previously paid, submit verification of prior payments (e.g., cancelled checks, receipts)
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For disability benefits, submit biennial letter from physician verifying Permanent Total Disability status, as defined in ORS 656.206, is unchanged.
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For family members who qualify due to full-time enrollment in school, submit verification of enrollment
SCHOLARSHIP BENEFITS
STANDARD BENEFIT FOR A GRADUATE PROGRAM OF HIGHER EDUCATION
For First-Time Applicants, please submit the following:
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Verification of enrollment in graduate program
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Verification applicant has exhausted the [federal] education benefits available under 28 C.F.R., Part 32, subpart B and has made application within one year from the date of exhaustion of those benefits.
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Verification of application for other available public education benefits
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Copy of tuition costs/fees from selected college
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Duration of time benefits are requested (i.e., quarter, semester, etc.)
For previously approved applicants, please submit the following:
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Verification of enrollment in graduate program
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Copy of tuition costs/fees from selected college
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Duration of time benefits are requested (i.e., quarter, semester, etc.)
ALTERNATE BENEFIT FOR AN UNDERGRADUATE PROGRAM:
(Note: Apply only if ineligible to receive benefits from federal program)
For First-Time Applicants, please submit the following:
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Verification of enrollment in undergraduate program
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Verification applicant was ineligible for federal education benefits available under 28 C.F.R., Part 32, subpart B.
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If applicant is a child or dependent of a public safety officer, submit verification of date applicant graduated from high school and verification applicant was a minor at the time a qualifying public safety officer suffered a qualifying death or disability (NOTE: Must apply within five (5) years from date of graduation)
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If applicant is a spouse of a public safety officer who suffered a qualifying death or disability, submit verification of marriage to officer. (NOTE: If applicant is public safety officer, must apply within five (5) from date of injury)
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Copy of tuition costs/fees from selected college
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Duration of time benefits are requested (i.e., quarter, semester, etc.)
For previously approved applicants, please submit the following
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Verification of enrollment in undergraduate program
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Copy of tuition costs/fees from selected college
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Duration of time benefits are requested (i.e., quarter, semester, etc.)
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