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Resolution No. 6621 . 1 RESOLUTION NO. 6621 2 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF VERNON DENYING THE DISABILITY RETIREMENT OF LOREN DOME, A LOCAL SAFETY MEMBER EMPLOYED BY THE CITY OF VERNON (Government Code sections 21024 and 21025) 3 4 5 WHEREAS, the City of Vernon (hereinafter referred to as is a contracting agency of the Public Employees' 6 "Agency" ) 7 Retirement System; and 8 WHEREAS, the Public Employees' Retirement Law requires 9 that a contracting agency determine whether an employee of such agency in employment in which he is classified as a local safety member is physically or mentally incapacitated to perform his duties 10 11 12 for purposes of the Public Employees' Retirement Law; and 13 WHEREAS, Loren Dome, employed by the Agency in the 14 position of Fire Engineer, on or about September 14, 1994, filed an 15 16 application for disability retirement with the Public Employees' Retirement System, and the Public Employees' Retirement System 17 requested the Agency, on or about February 14, 1995, to make a 18 determination regarding whether Loren Dome was incapacitated for the 19 performance of his duties and therefore eligible to retire for 20 disability; and 21 WHEREAS, by letter dated April 10, 1995, Bruce V. 22 Malkenhorst, the City Administrator, notified Loren Dome that, 23 unless Mr. Dome submitted document ion to justify approval by the City Council of his request for disability retirement, he would recommend to the City council that said request be denied; and 24 25 26 WHEREAS, the City Council of the city of Vernon has 27 reviewed medical evidence and other evidence relevant to Mr. Dome's 28 incapacity to perform his duties; and ... , '.. .' I " 1 WHEREAS, the City Council of the City of Vernon has 2 reviewed evidence both as to whether any incapacity was industrial 3 and as to whether any third-party liability is possible with respect 4 to any incapacity. 5 NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE 6 CITY OF VERNON AS FOLLOWS: 7 SECTION 1: The City Council of the city of Vernon hereby 8 finds and determines that Loren Dome is not incapacitated within the 9 meaning of the Public Employees' Retirement Law for the performance 10 of his duties in the position of Fire Engineer in the Vernon Fire 11 Department. 12 SECTION 2: The City Council of the city of Vernon hereby 13 denies the application of Loren Dome for disability retirement. 14 SECTION 3: The City Clerk shall notify Loren Dome and the 15 Public Employee Retirement System of the City Council's 16 determination denying his application for disability retirement. 17 SECTION 4: The City Clerk of the city of Vernon shall 18 certify to the passage of this resolution and thereupon and 19 thereafter the same shall be in full force and effect. 20 21 APPROVED AND ADOPTED this 2nd day of May, 1995. ~. '-'u,~) ---~oW'fi~;~& · 22 23 24 A?f BRUCE V. ~~ MALKENHORST, City Clerk 25 26 27 28 -2- - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 " .. _.. .I " STATE OF CALIFORNIA ) ) ss COUNTY OF LOS ANGELES ) I, BRUCE V. MALKENHORST, City Clerk of the City of Vernon, do hereby certify that the foregoing Resolution, being Resolution No. 6621, was duly adopted by the City Council of the City of Vernon at a regular meeting of the City Council duly held on Tuesday, May 2, 1995, and thereafter was duly signed by the Mayor of the City of Vernon. /- BRUCE V. (SEAL) -3- j S -==PERS Benefit Application Services DIVIsion P.O. Box 2796 Sacramento, CA 95812-2796 Telecommunications Device for the Deaf - (916) 326-3240 (916) 326-3232; FAX (916) 326-3934 REPLY TO: SECTION 436 REFER TO: 565-56-0688 June 23, 1995 I .. 2601 E. ictoria, #121 Rancho ,ominguez, CA 90220 / Dear Mr. Dome: This letter is in regard to the application for your disability retirement submitted on January 13, 1995. In accordance with Government Code Section 21025, your employer has determined that you are not incapacitated for the performance of your duties as a Fire Engineer. The City of Vernon has denied your disability retirement. Any appeal to this decision must be made to the City of Vernon. Your application will be cancelled after 30 days if PERS has not been notified that you have appealed the employer's decision. You will continue to receive your service retirement allowance. Sincerely, . ~tZ.~ Martha A. Barger, Manager Disability Determination Section MB:CS:cs CC:Jo209 - City of Vernon Callfomla Public Employees' Retirement System Uncoln Plaza - 400 P Street - Sacramento, CA 95814 CITY COUNCIL LEONIS C. MALBURG Mayor BRUCE V. MALKENHORST City Administrab:y;/Gty Clerk FAX: (213) 581-7924 . CITY HALL DAVID B. BREARLEY Gty Attorney FAX: (818) 330-5818 S. KEVIN WILSON Acting Director of Community Services & Water FAX: (213) 588-2761 KENNETHJ. DeDARIO Director of light & Power FAX: (213) 583-1983 DAVE TELFORD Fire Chief FAX: (213) 581-1385 LOUIS ROSENKRANTZ Police Chief FAX: (213) 581-1178 Wrn. "BILL" DAVIS Councilman THOMAS A. YBARRA Mayor Pro-Tern H. "LARRY" GONZALES Councilman W. MICHAEL McCORMICK Councilman 4305 SANTA FE AVENUE, VERNON, CALIFORNIA 90058 TELEPHONE (213) 583-8811 May 18, 1995 Cheryl Salvador, Disability Determination Section PERS Benefit Application Services Division P. O. Box 2796 Sacramento, CA 95812-2796 RE: Loren Dome, SS# 565 56 0688 SUBJECT: Determination of Eligibility for Disability Retirement Dear Ms. Salvador: On February 14, 1995, you requested, pursuant to Government Code ~21024, that the City Council of the City of Vernon make a determination re- garding whether Loren Dome, a local safety member employed by the City of Vernon, is physically or mentally incapacitated to perform duties and, therefore, eligible to retire for disability. On May 2, 1995, the City Council reviewed the medical evidence and other evidence relevant to whether Loren Dome is incapacitated for the perfor- mance of duties and determined that he is not incapacitated, by adopting Resolution No. 6621, a certified copy of which is attached hereto. Pursuant to Government Code ~21025, the City Council hereby notifies you of its determination that Loren Dome is not incapacitated. Very truly yours, CITY OF VEX ~alk~dft City Administrator cc: City Attorney Personnel Assistant BVM/gjo * ~PERS Benefit Application Services Division P.O. Box 2796 Sacramento, CA 95812-2796 Telecommunications Device for the Deaf (916) 326-3240 (916) 326-3232; FAX (916) 326-3934 00 rn @ rn D \17 rn f]J ~1AY 1 ~ 1995 · CITY ADMINISTRATOR'S OFFICE CITY OF VERNON REPLY TO: SECTION 432 REFER TO: 565-56-0688 May 8, 1995 ~0209 - City of Vernon ~ 016 Attn: Personnel Officer RE: Loren E. Dome Dear Personnel Officer: This is regarding the application for disability retirement forwarded to your office on January 30, 1995 for Loren E. Dome. Section 21025 of the California Government Code provides that, in the case of a local safety member, the governing body of the contracting agency employing such member shall determine whether the member is incapacitated for the performance of duty. Section 21025.1 requires that the determination be made within six months of the request from PERS. Please advise us of the current status of the determination process. Your prompt reply will be appreciated. Sincerely, Cheryl Salvador Disability Determination Section cc: Loren E. Domp ~ ~ ~ Victoria 121 .. Rancho Dominguez, CA 90220 PERS-BAS-321 (REV. 1/94) California Public Employees' Retirement System LIncoln Plaza - 400 P Street - Sacramento, CA 95814 . 1t BRUCE V. MALKENHORST City Administrat~r/City Clerk FAJ(:(213)581~7924 CITY HALL {)AVID B. BREARLEY _ 1"111 City Attorney < II X: (818) 330-5818 S- -/9 ). V v~~:.'::~ & w..., , \ . V..~ X~bJ '3) 588-2761 '\?" ~ \'-1 Ql r. DeDARIO :> ~'f~b /"f.} b::':- ~~~\ ~J~ )RD ~ ~~ -"J 581-1385 ty clJUIS ROSENKRANTZ Police Chief FAJ(: (213) 581-1178 CITY COUNCIL LEONIS C. MALBURG Mayor Wm. "BILL" DAVIS Councilman THOMAS A. YBARRA Mayor Pro-Tern H. "LARRY" GONZALES Councilman W. MICHAEL McCORMICK Councilman ~ 4305 SANTA FE AVENUE, VERNON, CALIFORNIA 90058 TELEPHONE (213) 583~881l May 4, 1995 , , Mr. Loren E. Dome 2601 E. Victoria #121 ~Rancho Dominguez, CA 90220 RE: Disability Determination by the City Council and Appeal Procedure Dear Mr. Dome: After a review of all medical evidence and other evidence relevant to your disability retirement request on May 2, 1995, the City Council has determined that your request for disability retirement is denied. The City Council made this determination through the adoption of Resolution No. 6621, a copy of which is attached to this letter and incorporated herein by this reference. You may appeal this determination in accordance with Government Code Section 21025, but any such appeal must be made within fifteen (15) days from the date of this letter. To make any such appeal, you must file a request for an appeal hearing by the City Council directly with me, and a written statement of the issues upon which the appeal hearing is sought must accompany your request. Within fifteen (15) days after your request is filed City staff will provide you with a response. Within thirty (30) days after City staff provides said response it will be presented to the City Council. The City Council will decide whether to grant the appeal hearing on any of the issues. If the appeal hearing is granted it shall take place before the City Council within fifteen (15) days after the decision to grant such an appeal hearing. If it is not granted, your request shall constitute a * Mr. Loren Dome RE: Disability Retirement May 4, 1995 page 2 notice of appeal, and your written statement of issues shall constitute a statement of appeal issues. Pursuant to Government Code Section 21025, an appeal hearing shall be arranged before an administrative law judge of the California Office of Administrative Hearings. The administrative law judge will notify you and the City of the hearing procedures and the date, time, and place of the hearing. .. If you have any questions regarding this matter, please do not hesitate to contact me. Very truly yours, .... CITY OF VERNON ."?w~tl,/Jld!~~ ~ce V. Malkenhorst . City Administrator/City Clerk BVM/gjo ~ cc: City Attorney (w/o attachment) Risk Manager (w/attachment) File : DsbltyAp. el CITY COUNCIL LEONlS C. MALBURG Mayor THOMAS A. YBARRA Mayor Pro-Tern Wrn. "BILL" DAVIS Councilman H. "LARRY" GONZALES CounciIman W. MICHAEL McCORMICK Councilman BRUCE V. MALKENHORST City Administrator/City Clerk FAX: (213) 581-7924 City Council City of Vernon Honorable Members: DAVID B. BREARLEY City Attorney FAX: (818) 33o-SS18 S. KEVIN WILSON Acting Director of Community Services & Water FAX: (213) 588-2761 KENNETH J. DeDARIO Director of Light & Power FAX: (213) .583-1983 DAVE TELFORD Fire Chief FAX: (213) 581-1385 LOUIS ROSENKRANTZ Police Chief FAX: (213) 581-1178 CITY HALL 4305 SANTA FE AVENUE, VERNON, CALIFORNIA 90058 TELEPHONE (213) 583-8811 April 26, 1995 Former Fire Engineer Loren Dome filed an application with the Public Employees Retirement System (PERS) for a disability retirement, and based on the report of John G. Dallas, M.D., it is hereby recommended that Mr. Dome's request be denied. BVM/hr * Very truly yours, A:A Bruce V. Malkenhorst City Clerk BRUCE V. MALKENHORST City Administrator/City Clerk FAX: (213) 581-7924 . , 4305 SANTA FE A VENUE, VERNON, CALIFORNIA 90058 TELEPHONE (213) 583-8811 April 10, 1995 .. CITY COUNCIL LEON IS C. MALBURG Mayor THOMAS A. YBARRA Mayor Pro-Tern Wm, "BILL" DA VIS Councilman H. "LARRY" GONZALES Councilman W. MICHAEL McCORMICK Councilman CITY HALL Mr. Loren E. Dome 2601 E. Victoria #121 'Rancho Dominguez, CA 90220 RE: Request for Disability Retirement Dear Mr. Dome: DA VID B. BREARLEY City Attorney FAX: (818) 330-5818 VICTOR H. V AITS Director of Community Services & Water FAX: (213) 588-2761 KENNETH J. DeDARIO Director of Light & Power FAX: (213) 583-1983 DAVE TELFORD Fire Chief FAX: (213) 581-1385 LOUIS ROSENKRANTZ Police Chief FAX: (213) 581-1178 In Reply Refer 10: The Public Employees Retirement System has notified the City that you filed a request for disability retirement with them on January 13, 1995. City Staff has reviewed your personnel file and also any workers' compensation proceedings involving you. This review does not appear to justify a determination by the City Council that you qualify for disability retirement in accordance with Government Code Sections 20124 and 21025. At this time, based upon information we have in our files, City staff would recommend that your request be denied. Government Code Section 21024 and Section 21025 provide that you are entitled to a hearing before the City Council to determine your request for disability retirement. If you disagree with our recommendation, please file a written notice of objections, including any information that you have which you believe would allow you to qualify for a disability retirement pursuant to Government Code Sections 21024 and 21025, directly with me within fifteen (15) days after you receive this letter. Upon receipt of any such written notice of objections, I will schedule a hearing before the City Council to determine whether you qualify for a disability retirement by reason of physical or mental incapacity, and will notify you when a hearing has been scheduled. Pursuant to Govern- ment Code Section 21025.1 any such hearing must be concluded within six (6) months of the city's receipt of your application for disability retirement. * .. Mr. Loren Dome RE: Request for Disability Retirement Page 2 At the hearing you will have the burden of proving that you are sub- stantially unable to perform your usual duties because of physical or mental incapacity, and you must produce competent medical evidence and opinion on that issue. You may be represented by counsel, and you will be able to present testimony under oath and to cross-examine any witness presented by the City. You must submit written legal arguments supporting your position at the hearing, and written proposed findings of fact and conclusions of law at the end of the hearing. Within thirty (301 days after the conclusion of the hearing, the City Council Mill ~ake written findings of fact and conclusions of law)and render its determination. If I do not receive any written notice of objections from you by noon on}\pril 27, 1995, I will recommend that the Ci ty Council adopt a resolution denying your request for disability retirement at its next regular meeting. 'If you have any further questions concerning this matter please contact Joan Francone, Risk Manager/Personnel Assistant. Very truly yours, CITY OF VERNON .1 / .7, .../~'/'/ ~ C,--L .. /, all ,//- ruc;;Z'~~ ;fa~?ny:;/;jl> 'LL' (i~ City Administrator/City Clerk BVM/gjo cc: City Attorney Risk Manager/Personnel Asst. :Dsbltyhr.Nts w/ SUBJECT: DISABILITY RETIREMENT- LOREN DOME, FIRE ENGINEER Loren Dome applied for a service retirement pending disability determination with PERS on September 14, 1994. PERS requested that the City make a determination in a letter dated January 30, 1995 and received by the City on February 14, 1995. His effective date of retirement was February 17, 1995. Mr. Dome was seen by John G. Dallas, M.D. Dr. Dallas was his personal choice of doctor for surgery to his right forearm as a result of an April 20, 1994 injury while on duty. Based upon the report of Dr. Dallas dated January 5, 1995, Mr. Dome is permanent and stationary. He has no work restrictions and may perform regular work. There are no other doctor's reports available indicating that Mr. Dome is disabled and deserving of a disability retirement, therefore, the application for disability retirement should be denied. If you are in concurrence with this recommendation, please send a notice to Mr. Dome advising him of Council's date and time for hearing under Government Code 21024 and 21025. JF/cp Attached cc: City Attorney d~~('t ~ c: \wp51 pers\domedis.deny ~/ lli'lJ~ 'lJ ~ IS ~ 4t\Q~ t t a \ It \.,""..,~ . JOR'S OFF\CE. erN AO~~\~~R~ERNON j'r~ -=PSRS Benefit Application Services Division P.O. Box 2796 Sacramento, CA 95812-2796 (916) 326-3232; FAX (916) 326-3934 Telecommunications Device For The Oeaf--(916) 326-3240 ~ tJAN 3 0 19951 0209 VERNON CITY -R1SKMtlMA,itm: Personnel Officer 14 fEBSS.. tUReiil DISABILITY RETIREMENT APPLICATION FOR: Name: Loren E. Dome Social Security Number: 565-56-0688 Birth Date: 10-05-41 Application Received: 01-13-95 Enclosed is a copy of the application which is being filed with your agency for a determination of the member's disability, in accordance with Section 21024 and 21025, Government Code. It is required that you make this determination within six months of this request unless the local safety member waives the requirements of this provision (Section 21025.1, Government Code). Under the Public Employees' Retirement Law, disability means the incapacity of a member for the performance of duty in public services for permanent or extended and uncertain duration, as determined on the basis of competent medical opinion. Disability is not necessarily an inability to perform every fuction of a given position. Rather, the courts have concluded that the test in any case is whether the employee can substantially perform the duties of the position he occupies. These criteria apply whether the member is being retired or is being reinstated from disability retirement. Disputed questions regarding the industrial relationship of the disabling injury to the member's work will be resolved by the Workers' Compensation Appeals Board. In the event there is no dispute, such a finding can be made by the employer. A Workers' Compensation Award is not sufficient evidence that a local safety member is disabled for retirement purposes. There must be a specific finding under Section 21026, Government Code, by the employer, with respect to the disability for which he will be retired. If it is determined that the member is not disabled for the performance of his duties, a Resolution to that effect must be filed with the System. Please refer to Sample resolution No.1, Benefits Procedures, Procedures Manual for Public Agency reporting to the Public Employees' Retirement System. If the member is found to be disabled, the fol1owinq will apply: California Public Employees' Retirement System lincoln Plaza-400 P Street-Sacramento, CA The Retirement System will require at least the following documentation: 1. A finding that disability exists. 2. a. A finding by your agency as to whether or not the disability is industrial. b. In case of a dispute, a Findings and Award by the WCAB, resolving the industrial relationship. 3. A certified statement (Resolution) by the local agency, indicating last day member is on payroll. In case of a dispute regarding the member's effective date of retire- ment, a request must be filed with the WCAB for Finding of Fact to determine on what date the member's condition became permanent and stationary. That date then becomes the effective date of retirement (Government Code Section 21025.4) . 4. A statement identifying the type of disability retirement determined, i.e., non-industrial disability retirement or industrial disability retirement. A member must have a minimum of five years of credited service to qualify for non-industrial disability retirement. If a member does not meet the minimum service requirements for disability retirement, he may still qualify by redepositing previously withdrawn contributions, or contributing an amount for service rendered prior to membership with the System. Time during which the member is absent from State service by reason of injury or illness, which is determined within one year after the end of such absence to be job-related, shall be considered as time spent in State service for the purpose of qualification for retirement and death benefits. 5. A statement by the agency to the effect that there is, or is not, a possibility of third-party liability present, if member's disability was caused by negligence or an intentional act of a party other than employer. 6. A statement identifying the reason for the disability, i.e. orthopedic, psychological, cardio-vascular, internal, neurological or other. 7. If advanced disability pension payments will be paid to the member, include the monthly amount. Also include where the reimbursement check should be mailed. 8. If the employee was hired after 1-1-80, include the following in accordance with C.C. Section 21292.6: a. Was the disability due to hazardous portions of duty? b. Was the disability due to a direct act perpetrated against the employee? California Public Employees' Retirement System Lincoln Plaza-400 P Street-Sacramento, CA . ~ . All such documentation submitted by your agency must be signed by the qoverninq body or its lawful delegate (City Manager, Chief Administrative Officer, County Executive, or other comparable individual). If the governing body chooses to delegate the responsibility of making a determination, a certified COpy of the deleqation order of this authority must accompany the findinqs bv such deleqate in each instance. Under the law, if a person (other than the employer) caused an injury that results in certain PERS benefits being paid, then PERS has the right to recover from the responsible person up to one-half of the total retirement benefit costs payable due to this injury. This right is known as a "right of subrogation". (Gov. Code sec. 21450 et seq.) Accordingly, the Retirement System requests that you, as the local agency, send us copies of all injury reports sent to the State Compensation Insurance Fund (or your Workers' Compensation carrier) concerning any and all injuries sustained by this employee. Please advise us if you are aware our member is pursuing a claim (other than a Workers' Compensation claim) against any person or entity for the same injuries that also entitle the member to a disability retirement from PERS. We hope the above information is helpful to you. If you have any questions, please call. CHERYL SALVADOR BENEFIT APPLICATION SERVICES DIVISION PUBLIC EMPLOYEES' RETIREMENT SYSTEM cc: Loren E. Dome PERS-BAS-175 (Rev. 1/91) California Public Employees' Retirement System Lincoln Plaza-400 P Street-Sacramento, CA -=PERS APPLICATION FOR RETIREMENT BENEFIT APPLICATION SERVICES DIVISION PUBLIC EMPLOYEES' RETIREMENT SYSTEM P.O. BOX 942711 SACRAMENTO, CALIFORNIA 94229-2711 Telephone: (916) 326-3232 Telecommunications Device for the Deaf (916) 326-3240 INSTRUCTIONS: Please read the important information on reverse side before completing this form. This application should be mailed directly to PERS 90 days in advance of your planned retirement date. Remember, your retirement date cannot be earlier than the first of the month in which your application is received by PERS. I hereby make application for Se.rv i c..e... (Service; Disability; or Industrial Disability) 1ST! S.p I J" II: 23 FOR PERS USE ONLY 1. SOCIAL SECURITY NO. Retirement as follows: 5(0 S -5~- 0<.088 Lot"el\ (Please Print} /2. Do V1'"\.Q... 3. Birth Date \0\5) ifl 4. Retirement Effective Date 2. Name libr\..lOJ ~ \81 \QC15 ~Mailing Address (Street, City, State, Zip) 2<.001 e. Vi cJoria. ~l2-l ~l cha \')om I n. q ue.~ I Q A- C'to22- D , 6. Last Day on Pay Status 7. Employer 8. Position Title f-ctJtUM'-j &1 I tqqs ~ of- Vli()O(\ {?~l (1.)I..Qf 9. OPTIONAL SETTLEMENT INFORMATION - Please furnish the amounts of monthly allowance payable under option checked. [Z( Unmodified ~ Option NO.1 0 Option No.2 lkJ Option No.3 10. BENEFICIARY'S NAME Birth Date Sex Relationship Ru~Y\ An {\. lx:><<U...- l\ 1 '2.'2-1 '-t z.; OM ~F 813\'1 \ /)J~f-€- 1,1. SURVIVOR INFORMATION: Are you married? 6?J Yes (Date of marriage ); D No Do you have children under 18? D Yes ~ No 12, TEMPORARY ANNUITY - I desire to have my monthly allowance further modified for life to provide for additional temporary annuity allowance, DYes 0 No If "Yes", age desired: Amount $ .00 59% or whole age 60 to 68 13. OTHER RETIREMENT SYSTEMS: Are you a member of another public retirement system other than Social Security or military? DYes I2i No If "Yes", please complete the section below. NAME OF SYSTEM DATES OF SERVICE CREDITED DATE OF RETIREMENT 14. FINAL COMPENSATION TO BE USED: "Final Compensation" is the highest compensation earnable by a member dUring the three consecutive years of employment immediately preceding the effective date of his/her retirement, or the date of his/her last separation from employment if earlier, or during any other period of three consecutive years of membership specified by the member on this application. UNLESS A DIFFERENT PERIOD IS SPECIFIED BY YOU, YOUR FINAL COMPENSATION WILL BE CALCULATED BASED UPON THE THREE YEAR PERIOD IMMEDIATELY PRECEDING YOUR RETIREMENT OR SEPARATION. OTHER PERIOD TO BE USED: FROM: TO: .... MEMBER'S SIGNATURE TELEPHONE NUMBER I . ~W-t't- e ./ ../l..-. . ,~' / b ,r,........ (~/O )?~f7'-:7S21 CALIFORNIA PUBLIC EMPLOYEES' RETIREMENT SYSTEM 409 P STREET - SACRAMENTO, CALIFORNIA PERS-BAS-369 (REV 12/91) ,~ ":a. .-fiiP"s"s Benefit Application Services Division P.O. Box 2796 Sacramento, CA 95812-2796 (916) 326-3232; FAX (916) 326-3934 Telecommunications Device For The Deaf--(916) 326-3240 Reply to: Refer to: Section 432 565-56-0688 E. Dome Victoria 121 ominguez Ca 90220 Dear Loren E. Dome : This letter acknowledges receipt of an application for your disability retirement. A copy of the application has been . forwarded to your employer for a determination of your disability. It is required that they make this determination within six months of our request unless you waive the requirements of this provision (Section 21025.1, Government Code). Following your employer's finding of substantial incapacity, your retirement cannot be cancelled. However, if you are eligible, and wish to change to a service retirement in lieu of disability retirement, you must apply for the change prior to the effective date of your disability retirement or within 30 days after notification of approval (Section 21025, Government Code). Under the law, if a person (other than your employer) caused an injury that results in certain PERS benefits being paid, then PERS has the right to recover from the responsible person up to one-half of the total retirement benefit costs payable due to this injury. This right is known as a "right of subrogation" (Gov. Code section 21450 et seq.). If you pursue a claim against any person for the same injuries that also entitle you to disability retirement from PERS (other than a Workers' Compensation claim or an uninsured motorist claim) YOU MUST INFORM PERS OF THE EXISTENCE OF THIS CLAIM. This is true even if the claim has not yet resulted in a court action. PERS has the right to participate in any such claim either through filing its own action against the responsible party, intervening in your claim, or filing a lien against any judgment which you may recover. IF YOU SETTLE SUCH A CLAIM WITHOUT NOTIFYING PERS, PERS MAY ALSO BE ENTITLED TO FILE A LAWSUIT AGAINST YOU FOR RECOVERY OF PERS' SUBROGATION RIGHTS. California Public Employees' Retirement System Uncoln Plaza-400 P Street.Sacramento, CA . .J "'''''& If you entered your safety membership category after January 1, 1980, your industrial disability allowance may be less than 50% of your final compensation. The allowance cannot exceed the amount that would be payable for a service retirement at age 55 if you had continued in employment until age 55. This limit qoes not apply if your agency has contracted to offer the 50% - 90% industrial disability allowance, or if you were disabled because of a direct violent act upon 'your person or as a result of hazardous and danqerous duty required for your position (Section 21292.6, Government Code). If you are notified by PERS that your disability application has been approved, and upon receipt of a separation document from your employer reflectinq your last day on the payroll, the System will calculate and send the optional settlement information that you requested on your application. This information will be sent to you on our form PERS-BAS-898, Election of Optional Settlement and Beneficiary Designation. The form will require the notarized signature of both you and your spouse. If at any time prior to the mailinq of your first warrant you wish to receive a refund of your accumulated contributions in a lump sum in lieu of a retirement allowance, you may do so by sendinq written notification to the return address shown above. Membership in PERS terminates upon the mailinq of a warrant refundinq contributions, makinq you ineliqible for future benefits unless you return to employment covered by PERS (Section 20390, Government Code) . If you have any questions, please contact us. Sincerely, CHERYL SALVADOR BENEFIT APPLICATION SERVICES DIVISION ~ cc: 0209 VERNON CITY PFRS-BAS-183B (Rev. 1/91) California Public Employees' Retirement System Lincoln Plaza-400 P Street-Sacramento, CA : :. ORTHOPEDIC SURGERY AND SPORTS MEDICINE GROUP J. GREGORY DALLAS, M.D. BRUCE M. WATANABE, M.D. ROBERT J. BOHR, M.D. DANIEL E. KAPLAN, M.D. 'R 1400 S. Harbor Blvd.. Suite A. La Habra. CA 90631-7520 (714) 879-3400 (800) 867-7572 FAX (714) 441-1998 o 10210 Orr & Day Road. Suite B. Santa Fe Springs. CA 90670-3595 (310) 864-2518 (800) 867-7574 FAX (310) 864-0339 January 5, 1995 -RlSlC...,MUMt,.l:"""I Colen & Lee Insurance 1470 South Valley vista Drive 2lJAN95 7: ~14i te 230 Diamond Bar, California 91765 Attention: Barbara McIntyre RE: Emp: DOl: LOREN DOME Vernon Fire Department 20 April 1994 SUPPLEMENTAL AND FINAL REPORT Dear Ms. McIntyre: Loren Dome is seen in orthopedic follow-up today, 5 January 1995. This patient is approaching 5 months status post right upper ex- tremity surgery with decompression of the medial nerve at the wrist and decompression of the ulnar nerve at the elbow. The patient states he is doing well overall referable to in- creased motion, diminished pain, and increased sensation. The patient states he is working at modified work currently and is due to retire on 17 February 1995. EXAMINATION: Right hand and wrist examination reveals well healed surgical wounds. There is no tenderness, induration, or swelling present. The patient demonstrates full range of motion. He is able to make a full fist. Examination of the right elbow reveals well healed surgical wounds. There is no tenderness to palpation. Range of motion testin~ is essentially equal bilaterally, but the patient does lack 5 of full extension. Neurologic evaluation is without localizing deficit. Tinel's sign is negative. Phalen's test is negative. Measurements: Maximum forearm circumference 12" on the right and 11-3/4" on the left. ~ Colen & Lee Insurance RE: LOREN DOME January 5, 1995 Page Two Jamar grip testing in pounds reveals 100/95/95 on the right and 95/90/90 on the left. The patient is right-hand dominant. FINAL DIAGNOSIS: 1. RIGHT ULNAR NERVE NEURITIS AND ULNAR NERVE ENTRAPMENT, IMPROVED POSTOPERATIVELY. 2. STATUS POST RIGHT CARPAL TUNNEL DECOMPRESSION. DISABILITY STATUS: At this time, it is felt this patient has clinically plateaued and reached the maximum benefit of conser~ vative treatment and may be considered permanent and stationary referable to the above injury. FUTURE MEDICAL CARE: It is recommended that consideration be given to the provision for future orthopedic treatment in this case, as periodic exacerbations may occur requiring the use of non-narcotic analgesic and anti-inflammatory medication. The patient is given Myoflex Creme in the office today. WORK RESTRICTIONS: None. WORK STATUS: The patient may perform regular work. FACTORS OF PERMANENT DISABILITY: Obiective: 1. Findings as noted at the time of surgery. 2. Slight loss of right elbow extension of 50. Subiective: 1. Slight weakness in the right upper extremity. Sensation is within normal limits. 2. Right upper extremity aching discomfort which would be con- sistent with intermittent and minimal with activities of daily living. ,,- - ~ Colen & Lee Insurance RE: LOREN DOME January 5, 1995 Page Three APPORTIONMENT: There is no indication for apportionment. COMMENTS: If there are further questions, please do not hesitate to call. This patient is not scheduled for a definite return appointment. Thank you for allowing me the opportunity to evaluate and parti- cipate in the care of this patient. I would be happy to re- evaluate him at any time in the future. Sincerely, ~~~~~D. JGD/bcs*-lh ~~,,'" ~" ORTHOPEDIC SURGERY AND SPORTS MEDICINE GROUP 1400 South Harbor Boulevard Suite A La Habra, CA 90631-7520 714/879-3400 - 800/867-7572 AFFIDAVIT OF COMPLIANCE LOREN DOME DOl: 20 April 1994 Date of report: 05 January 1995 I declare under penalty of perjury that the information contained in the attached report is true and correct to the best of my knowledge and belief, except as to informa- tion that I have indicated I received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and, except as noted herein, that I believe is to be true. I declare under penalty of perjury that I have not violat- ed Labor Code 139.3 and the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief except as to informa- tion that I have indicated I received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and, except as noted herein, that I believe it to be true. ~. Dated this 13th day of January, 1995, at Orange County, California. Thank you for allowing us to examine this patient. In the attached letter, I have attempted to address all the ques tions which normally arise in situations of this nature. However, if you have any further questions regarding this case, please do not hesitate to contact our office. _l~A G1.~#h JoLn G. Dallas, M.D. JG~bcS Enclosures _tlikjo~>.n.h.\~\l"i)~.'''" ;~),).;,,) \h)',)<. '~', .". ,. r:;y// \\ ~ ~ llig @ \?:J U ~ ~ < -\Q_C.;~\ r.... n \ Ii \c>...,- rt-v TOR'S orf\CE crt'< AD~~~\~~R~ERNON )Jr~ -=PERS Benefit Application Services Division P.O. Box 2796 Sacramento. CA 95812-2796 (916) 326-3232; FAX (916) 326-3934 Telecommunications Device For The Deaf-(916) 326-3240 - fJAN 3 0 1995J 0209 VERNON CITY Attn: Personnel Officer Re: DISABILITY RETIREMENT APPLICATION FOR: Name: Loren E. Dome Social Security Number: 565-56-0688 Birth Date: 10-05-41 Application Received: 01-13-95 Enclosed is a copy of the application which is being filed with your agency for a determination of the member's disability, in accordance with Section 21024 and 21025, Government Code. It is required that you make this determination within six months of this request unless the local safety member waives the requirements of this provision (Section 21025.1, Government Code). Under the Public Employees' Retirement Law, disability means the incapacity of a member for the performance of duty in public services for permanent or extended and uncertain duration, as determined on the basis of competent medical opinion. Disability is not necessarily an inability to perform every fuction of a given position. Rather, the courts have concluded that the test in any case is whether the employee can substantially perform the duties of the position he occupies. These criteria apply whether the member is being retired or is being reinstated from disability retirement. Disputed questions regarding the industrial relationship of the disabling injury to the member's work will be resolved by the Workers' Compensation Appeals Board. In the event there is no dispute, such a finding can be made by the employer. A Workers' Compensation Award is not sufficient evidence that a local safety member is disabled for retirement purposes. There must be a specific finding under Section 21026, Government Code, by the employer, with respect to the disability for which he will be retired. If it is determined that the member is not disabled for the performance of his duties, a Resolution to that effect must be filed with the System. Please refer to Sample resolution No.1, Benefits Procedures, Procedures Manual for Public Agency reporting to the Public Employees' Retirement System. If the member is found to be disabled, the following will apply: California Public Employees' Retirement System Lincoln Plaza-400 P Street-Sacramento, CA "