These Claim Forms are provided by the Pension Board for your convenience. They will assist you with filing claims and receiving benefits.
The forms may be downloaded in two formats:
Microsoft Word: To download the forms in this format right click on the appropriate link below and select Save As, then select the directory on your computer that you wish to save the document in.
Note: You may be able to view the forms in this format without downloading them by left clicking on the links below if your browser is properly configured and you have Word installed on your computer.
Adobe Portable Document Format (PDF): To view or download the files in this format you must have Adobe Acrobat Reader installed on your computer. This is a free program from Adobe. To download, right click on the appropriate link below and select Save As and select the directory you wish to save the document to. To view the document online in Acrobat Reader, simply left click on the link for the appropriate document.
If you have any questions or are unable to read or download these documents please contact the Pension Board and request that copies be sent to you.
Please select a link below
LEOFF 1 Claim/Referral Form
Referral Claim Form - Active Members: PDF format | Word format
Referral Claim Form - Retired Members: PDF format | Word format
Medical Claim Form: PDF format | Word format
LEOFF 1 Statement of Other Health/Medical Benefits
Other Benefits Form: PDF format | Word format
Policy and Procedures are also available