HELPFUL HINT:
You should file
for both Disability Leave and Workers' Compensation at the same time. Filing for both
may make you eligible for Disability Advancement.

Step 1
If you become disabled, follow your agency's standard reporting procedure.

Step 2
Get the Application for Disability Leave Benefits (Form ADM 4310), from your personnel office. [This form can also be downloaded from the Benefits Administration Services Web site. Click here to visit the Benefits Forms Web page for more information.]

Step 3
Complete the employee portion (pages 2 and 3) of the Application for Disability Leave Benefits.

Step 4
Give all five pages of the application to your health care provider so that he/she may fill out the attending physician portion (pages 4 and 5) of the application. Pick up the completed form and return it to your personnel officer within 20 calendar days of your last day worked. Please make sure that your provider keeps his/her copy of the application.

Step 5
Your agency's personnel office will then complete the Employer Statement (Form ADM 4312), make a recommendation on your claim, and forward it to the Department of Administrative Services. [Employers - This form can be downloaded from the Benefits Administration Services Web site. Click here to visit the Benefits Forms Web page for more information.]

Step 6
If you are asked to submit more information, or if your condition changes, complete the employee portion (page 2) of the Supplemental Report (Form ADM 4311). Take the form to your health care provider so that he/she may fill out the rest of the form (pages 3 and 4). Return it to your agency's personnel office promptly. [This form can also be downloaded from the Benefits Administration Services Web site. Click here to visit the Benefits Forms Web page for more information.]