Law Enforcement and Fire Fighters Disability Online Application

Tell us how your injury occurred:

Were you acting in the line of duty at the time of the incident? Yes No

Have you previously had the same/similar injury? If so, when?

Have you filed, or do you plan to file, for Workers’ Compensation? Yes No

Physician/Healthcare Provider Information:

Physician Name:

Mailing Address:

Phone Number:  

Certification: I certify that the above information is true and complete to the best of my knowledge. I know that any misrepresentation herein may lead to a rejection of this application, and the Mississippi Attorney General’s Office has the right to commence civil and/or criminal action for the misrepresentation of such information.

If applicable, I signed on behalf of the applicant as legal representative. (Please attach a copy of documentation authorizing legal representation.) 

Diagnosis/primary disabling condition:

Has this patient been treated for the same/similar condition prior to this occurrence?  If so, list related diagnoses & dates of treatment:

Is this patient temporarily disabled? Yes No If yes, what are the temporary restrictions/limitations?

Anticipated return to work/release date: If undetermined, based on your medical knowledge, what is a reasonable time frame before you expect to be able to release this patient to return to work?

Name of Physician:

Phone:

Fax:

Address:

Email Address:

Patient #:

Name of Employer:

Phone Number:

Mailing Address:

Email Address:

Fax Number:

Employee’s Job Title:

For the purposes of determining eligibility for benefits, Section 45-2-21, Mississippi Code Annotated (1972) sets forth the following definitions:

    “Fire fighter” means an individual who is trained for the prevention and control of the loss of life and property from fire or other emergencies, who is assigned to firefighting activity, and is required to respond to alarms and perform emergency actions at the location of a fire, hazardous materials or other emergency incident.

    “Law enforcement officer” means any lawfully sworn officer or employee of the state or any political subdivision of the state whose duties require the officer or employee to investigate, pursue, apprehend, arrest, transport or maintain custody of persons who are charged with, suspected of committing, or convicted of a crime.

This employee does does not (select one) meet the criteria of one of the above definitions. Please attach a copy of the employee’s Professional Certificate as being qualified to be a Mississippi Law Enforcement Officer or Fire Fighter to this application. (For Fire Fighters employed prior to 1991, please provide proof of employment prior to 1991.)

Average hours per week the employee worked prior to this incident: hours week

Monthly Salary $ Annual Salary $

Has the employee returned to work? Yes No Date Employee returned to work:

Has Workers’ Compensation been applied for?  Yes No

Approved? Yes No

Name, address and phone number of Workers’ Compensation carrier:

Is this condition the result of an accidental or intentional injury received in the line of duty as the result of a single incident? Yes No

If yes, please provide the date and description of the incident:

    For the purpose of evaluating my eligibility for benefits including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application, I hereby authorize the disclosure of information from my physician/healthcare provider and from my employer to the Mississippi Attorney General’s Office or its authorized representatives.

    Health information may be disclosed by any physician or healthcare provider that has any records or knowledge about the incident referred to on this application. Non health information including earnings or employment history or any other facts deemed appropriate by the Mississippi Attorney General’s Office or its authorized representatives to evaluate my application may be disclosed by any entity, person or organization that has records about me, including, but not limited to, my employer, employer representative and compensation sources.

    Any information the Mississippi Attorney General’s Office or its authorized representatives obtain pursuant to this authorization will be used only for the purpose of evaluating and administering my application for benefits. The Mississippi Attorney General’s Office or its authorized representatives will not disclose any information unless permitted by federal and/or state laws. I further authorize the Mississippi Attorney General’s Office to notify my employer of any benefits received and any employer responsibilities as related to my claim.

    This authorization is valid for two (2) years from its execution, and a copy is as valid as the original. I know that I may request a copy of this authorization to request this information. This authorization may be revoked by me at any time except to the extent the Mississippi Attorney General’s Office or its authorized representatives has relied on the authorization prior to notice of revocation. If revoked, the Mississippi Attorney General’s Office or its authorized representatives may not be able to evaluate my application for benefits. I may revoke this authorization by sending written notice to: Mississippi Attorney General’s Office, c/o Law Enforcement Officers and Fire Fighters Disability Benefits Trust Fund, P. O. Box 220, Jackson, MS 39205.

    You may refuse to sign this form; however, the Mississippi Attorney General’s Office or its authorized representatives will not be able to evaluate your application or administer your claim for benefits.

If applicable, I signed on behalf of the applicant as legal representative. (Please attach a copy of documentation authorizing legal representation.)