| Application Type |
Triggering Question |
Document Type |
Association |
Instructions |
|
| Death Part B |
Cause of Injury. Any selection: |
Investigation, Incident, and/or Accident Report |
<Agency> |
The investigation, accident and/or incident report is an official document on agency letterhead that includes the narrative description of the incident which resulted in the Public Safety Officer’s death. The investigation, accident and/or incident report can be obtained from the law enforcement agency conducting the investigation. |
|
| Statement of Circumstances. If elects to upload instead of typing in the text box: |
Statement of Circumstances |
<Agency> |
A detailed statement of circumstances is a written summary of the on-duty incident that led to the Public Safety Officer's death. The document should summarize the incident, and provide descriptive information on the officer’s fatal injury. The statement must be on agency letterhead and be signed by the agency head or designee. |
|
| 24 Hour Activity Report. If elects to upload instead of using the grid: |
24 Hour Report |
<Agency> |
When the Public Safety Officer's cause of death is confirmed to be a heart attack, stroke, or vascular rupture, the PSOB Office requires a statement on agency letterhead and signed by the agency head or designee that describes the 24 hour period leading to the onset of the Officer’s heart attack, stroke, or vascular rupture. The 24 hour report should include a description or detailed list of all the Officer’s on duty activities that occurred during the 24 hour period. |
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| Has a final determination been issued for any of the following? If State Line of Duty Death Benefits: |
Other Benefits |
<State Line of Duty Death Benefits Decision> |
The State Line of Duty Death Benefit final decision is an evidentiary document certifying that a decision has been rendered on a State Line of Duty Death claim. |
|
| Has a final determination been issued for any of the following? If Workers’ Compensation: |
Other Benefits |
<Workers’ Compensation Decision> |
The Workers’ Compensation final decision is an evidentiary document certifying that a decision has been rendered on a Workers’ Compensation claim. |
|
| Has a final determination been issued for any of the following? If Federal Employees' Compensation Act: |
Other Benefits |
<Federal Employees' Compensation Act Decision> |
The Federal Employees' Compensation Act (FECA) final decision is an evidentiary document certifying that a decision has been rendered on a FECA claim. |
|
| Has a final determination been issued for any of the following? If DC Retirement and Disability Act: |
Other Benefits |
<DC Retirement and Disability Act Decision> |
The DC Retirement and Disability Act final decision is an evidentiary document certifying that a decision has been rendered on a DC Retirement and Disability claim. |
|
| Has a final determination been issued for any of the following? If September 11th Victim Compensation Fund: |
Other Benefits |
<September 11th Victim Compensation Fund Decision> |
The September 11th Victim Compensation Fund (VCF) final decision is an evidentiary document certifying that a decision has been rendered on a September 11th VCF claim. |
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| In which capacity are you filling this application? If Authorized Representative: |
<Letter of Representation> |
<Authorized Representative> |
Provide a letter of representation stating that the authorized representative has the authority to act on the claimant’s behalf. |
|
| Has a final determination been issued for any of the following? If Medical Retirement/Disability: |
Other Benefits |
Medical Retirement/ Disability Decision |
The Medical Retirement/Disability Decision is an evidentiary document certifying that a final decision has been rendered on a Medical Retirement/Disability claim. |
| Has a final determination been issued for any of the following? If Workers’ Compensation: |
Other Benefits |
Workers’ Compensation Decision |
The Workers’ Compensation final decision is an evidentiary document certifying that a decision has been rendered on a Workers’ Compensation claim. |
|
| Has a final determination been issued for any of the following? If Social Security: |
Other Benefits |
Social Security Decision |
The Social Security Decision is an evidentiary document certifying that a final decision has been rendered on a Social Security claim. |
| Has a final determination been issued for any of the following? If Federal Employees' Compensation Act: |
Other Benefits |
Federal Employees' Compensation Act Decision |
The Federal Employees' Compensation Act (FECA) final decision is an evidentiary document certifying that a decision has been rendered on a FECA claim. |
|
| Has a final determination been issued for any of the following? If D.C. Retirement and Disability Act: |
Other Benefits |
DC Retirement and Disability Act Decision |
The DC Retirement and Disability Act final decision is an evidentiary document certifying that a decision has been rendered on a DC Retirement and Disability claim. |
|
| Has a final determination been issued for any of the following? If September 11th Victim Compensation Fund: |
Other Benefits |
September 11th Victim Compensation Fund Decision |
The September 11th Victim Compensation Fund (VCF) final decision is an evidentiary document certifying that a decision has been rendered on a September 11th VCF claim. |
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