Handling PSEBA Claims Administratively Keith L. Hunt Hunt & Associates P.C. Three First National Plaza Suite 2100 Chicago, IL 60602 312-558-1300 khunt@huntassoclaw.com

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The Public Safety Employee Benefit Act (PSEBA) 820 ILCS §320/1 (2015)

provides no process for evaluating benefit claims. The statute does not proscribe a

process nor identify a venue for handling those issues. When confronted with a PSEBA

claim what should a municipality do? There are three approaches to handling PSEBA

claims. One approach is to simply pay the claim – not a very effective way to challenge

questionable claims. A second approach is through the courts. A municipality may

choose to file a declaratory judgment action under 735 I LCS §5/2 – 701 (2015). This

approach can be very costly and effectively shifts the burden of proof to the municipality

to establish that an injured officer or firefighter is not entitled to benefits. A third and far

more effective approach is to create an administrative process by ordinance which sets

out the respective rights and responsibilities of a PSEBA applicant and the municipality.

This approach allows the burden of proof to remain with the applicant – – to establish

the entitlement to benefits. This approach is also far less costly.

AUTHORITY TO CONDUCT ADMINISTRATIVE HEARINGS

The Public Safety Employee Benefits Act (PSEBA) provides that a police officer

or firefighter who suffers a catastrophic injury (or death) is entitled to have their

employer pay 100% of the health insurance premiums for themselves, their spouse and

any dependent children if they can establish that (1) the injury was catastrophic; and (2)

it occurred while responding to “fresh pursuit, the officer or firefighter's response to

what is reasonably believed to be an emergency, an unlawful act perpetrated by

another, or during the investigation of a criminal act.” 820 ILCS §320/10.

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How is that determination made? What are the standards? Who conducts the

hearing? The PSEBA statute is silent on these issues. Do all municipalities have the

authority to conduct hearings to determine PSEBA benefits? May a municipality enact

an ordinance creating its own internal administrative process? The clear answer is it

depends.

Fire Districts – Gaffney v. Orland Fire Protection District

In Gaffney v. Orland Fire Protection District, the Illinois Supreme Court held that

a local fire protection district lacked the authority to adjudicate PSEBA eligibility.

Gaffney, 2012 IL 110012 (February 17, 2012). The Court reasoned administrative

bodies possess only those powers expressly granted by the Legislature – an application

of Dillon’s rule. The Supreme Court concluded the Fire Protection District Act did not

authorize the District to adjudicate administrative claims and therefore the District

lacked the authority deny the claim for benefits or to require that an applicant seek

administrative review. The Court reversed the Circuit Court’s decision upholding the

District’s denial of benefits.

Home Rule Units – Pedersen v. Village of Hoffman Estates

Home rule municipalities clearly have the authority to conduct administrative

hearings to determine eligibility for PSEBA benefits under Pedersen v. Village of

Hoffman Estates, 2014 IL App (1st) 123402 (March 31, 2014). In Pedersen, a firefighter

was injured in the line of duty and sought PSEBA benefits. The Village adopted an

ordinance creating an administrative process for determining the eligibility for PSEBA

benefits, designating the Village Manager as the Chief Administrative Hearing Officer.

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The Applicant objected to the process arguing that the Village process was not

authorized by the PSEBA statute itself, nor by the Illinois Constitution. After an

administrative hearing, the Village Manager rendered a written decision denying the

application for PSEBA benefits.

The Applicant then filed a Declaratory Judgment action seeking a declaration that

the Village was obligated to pay PSEBA benefits and seeking a declaration that the

ordinance creating the administrative process violated both the PSEBA statute itself and

the Illinois and US Constitutions. The Illinois Appellate Court upheld the ordinance

creating the administrative process stating:

Plaintiffs argue the circuit court's ruling is contrary to the decision in Gaffney. In that case, our supreme court ruled the circuit court erred in dismissing a firefighter's complaint for a declaratory judgment of his entitlement to benefits under section 10 of the Act and treating his alternative claim for administrative review as seeking a common law writ of certiorari. Gaffney, 2012 IL 110012, ¶ 30. The supreme court observed the defendant—the board of trustees of a fire protection district—was an administrative agency with no general or common law powers, and was limited to those powers specifically authorized by statute. Gaffney, 2012 IL 110012, ¶ 38. HN6 The court's review of the Fire Protection District Act (70 ILCS 705/0.01 et seq. (West 2010)) revealed no provision indicating that the legislature intended the board's denial of section 10 benefits to be an administrative decision subject to administrative review. Gaffney, 2012 IL 110012, ¶ 43. The court also observed the Act itself does not provide any guidance on the proper procedure for seeking section 10 benefits. Gaffney, 2012 IL 110012, ¶ 44. Accordingly, the court concluded the legislature did not express an intent to provide the fire protection district with the authority to make administrative decisions on its employees' eligibility for section 10 benefits under the Act. Gaffney, 2012 IL 110012, ¶ 45. Consequently, the court also concluded the board's decision was "not an administrative agency action, but [was] only an employer's objection to paying section 10 benefits." Gaffney, 2012 IL 110012, ¶ 45. Thus, our supreme court ultimately concluded the circuit court erred in dismissing the declaratory judgment count of Gaffney's complaint seeking relief under the Act. Gaffney, 2012 IL 110012, ¶ 45.

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Pedersen at ¶¶ 29-30. The Court concluded that Article VII, § 6(a) of the Illinois

Constitution granted home rule powers to municipalities, finding the Village clearly had

the home rule authority to enact an administrative process for adjudicating PSEBA

eligibility.

Non-Home Rule Units

There is an open question as to whether non-home rule municipalities have the

authority to adjudicate PSEBA claims. Gaffney and Pederson provide some insight

but neither case resolves the issue. In Gaffney, the Court concluded that a fire

protection district was an administrative agency and as such it lacked any authority

other than those powers expressly granted by the Legislature. Pedersen, on the other

hand, was decided based on the constitutional grant of home rule authority. But what

about non-home rule municipalities? No reported decision has analyzed grant of power

to municipalities under the Illinois Municipal Code.

The following are some of the powers expressly granted to municipalities under the

Illinois Municipal Code:

• The corporate authorities of each municipality may pass all ordinances and make all rules and regulations proper or necessary, to carry into effect the powers granted to municipalities, with such fines or penalties as may be deemed proper 65 ILCS 5/1-2-1

• The corporate authorities may control the finances of the corporation. 65 ILCS 5/8-1-1

• The corporate authorities of any municipality may provide by ordinance in regard to the relation between all municipal officers and employees in respect to each other, the municipality, and the people. 65 ILCS 5/10-4-1 This is the section authorizing municipalities to regulate the terms and conditions of employment and to enact ordinances to achieve those ends.

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• The corporate authorities of any municipality may arrange to provide, for the benefit of employees of the municipality, group life, health, accident, hospital, and medical insurance, or any one or any combination of those types of insurance, and may arrange to provide that insurance for the benefit of the spouses or dependents of those employees. …. The corporate authorities may provide for payment by the municipality of a portion of the premium or charge for the insurance with the employee paying the balance of the premium or charge. If the corporate authorities undertake a plan under which the municipality pays a portion of the premium or charge, the corporate authorities shall provide for withholding and deducting from the compensation of those municipal employees who consent to join the plan the balance of the premium or charge for the insurance. 65 ILCS 5/10-4-2

When read together, either alone or in combination with other specifically-enumerated

powers as granted by the Legislature, an argument may be made that non-home rule

municipalities also have the authority to create administrative processes for determining

PSEBA claims.

CREATING AN ADMINISTRATIVE PROCESS

Assuming a municipality elects to create its own internal administrative process,

as opposed to relying on the Courts through a declaratory judgment proceeding, a

municipality should adopt a clearly-defined policy and articulate a specific process for

the consideration and adjudication of PSEBA claims.

1. Adopt By Ordinance.

A municipality should create its own administrative process and procedures

which should be adopted by ordinance. Having a predetermined, published process will

make the outcome of any hearing less susceptible to attack. As a starting point, the

process should be objective. It should ensure due process and an adequate

opportunity for an applicant to submit evidence and to be heard. It should provide a right

of cross-examination in the creation of a written record which can be later reviewed. It

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is recommended that the process be conducted by an outside hearing officer, not an

individual who is regularly employed by the Village—simply in an effort to promote

objectivity and to create distance between the hearing officer and the municipality itself.

It is also helpful if the hearing officer is either a municipal attorney or a retired judge with

experience hearing municipal matters so that the individual is familiar with the rights and

property interests held by public employees.

The process should also provide that the applicant submit copies of any medical

records, pension board proceedings, transcripts, physician reports, photographs or

videos and any other evidence which will tend to prove or disprove the catastrophic

nature of the injury and the circumstances under which it occurred. Municipalities

should be sure to obtain the required HIPAA waivers as well as consent forms to obtain

medical information and other pertinent records for consideration in the process.

Attached to these materials are a sample Ordinance and sample PSEBA

Application and Policy to use as a model in creating an internal PSEBA procedure. The

process should delineate the rights and responsibilities of both the municipality and an

applicant.

2. Conducting The Trial

Note use of the word “trial.” It is not merely a hearing or an informal meeting. If

the record is to be reviewed in a later proceeding, it will be either through an

administrative review action or a common-law writ for certiorari. It is important that

process be treated like any other trial. The rules of evidence should be followed and a

cautious practitioner will insist that appropriate witnesses be called and documents be

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properly introduced into evidence. This not only ensures a better record but also holds

an applicant to the required standard of proof.

The process should include a formalized hearing where the evidence is taken

down by a court reporter. Although the Pedersen decision held that a municipality may

not require that the appeals process be taken pursuant to the administrative review act,

a formalized record is nevertheless required irrespective of the standard or vehicle for

review. Municipalities should insist that the rules of evidence be followed.

An attorney should also carefully consider whether to stipulate to the admissibility

of any medical records, reports or written statements. Such documents by their very

nature are hearsay, unless they can be admitted as a business record. Illinois Supreme

Court Rule 236 provides that medical records may be admitted as business records

provided the records are authenticated in a proper foundation can be laid. Troyan v.

Reyes, 367 Ill. App. 3d 729 (2006). Under Troyan, a person familiar with the business

and its mode of operation may provide testimony establishing the foundational

requirements of a business record. It need not be the author.

THE IMPACT OF THE PENSION PROCEEDING

If the pension board rules before a hearing on the PSEBA application, an issue

may exist regarding whether the pension ruling bars a municipality from relitigating the

issue. The answer depends on whether the municipality was a party to the pension

proceeding and in what appellate court district the matter was heard. There presently is

a conflict among the appellate courts on whether a pension board decision precludes a

municipality from litigating the nature, extent or causation of an injury in the PSEBA

process.

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The First District Appellate Court has held that a pension board ruling does not

bar a municipality from litigating PSEBA issues. Pedersen v. Vill. of Hoffman Estates,

2014 IL App (1st) 123402 (March 31, 2014); Oskroba v. Vill. of Hoffman Estates, 404 Ill.

App. 3d 692, 694, 343 Ill. Dec. 588, 590, 935 N.E.2d 596, 598 (2010). In Oskroba, the

First District rejected the argument that a village was barred from litigating the issue

under collateral estoppel. Oskroba, 404 Ill. App. at 696. The court reasoned that the

issues in pension disability proceedings differ from those in PSEBA proceedings. Id.

The Second District reached the opposite conclusion in Vill. Of Vernon Hills v.

Heelan. In that case, the Appellate Court affirmed a circuit court ruling which barred a

village from taking any discovery or introducing any evidence on the nature, extent or

causation of the officer’s injury. Vill. of Vernon Hills v. Heelan, 2014 IL App (2d) 130823

(July 23, 2014), leave to appeal granted 2014 Ill. LEXIS 1426, 386 Ill. Dec. 800, 21

N.E.3d 719 (oral argument May 20, 2015). Relying on its earlier interpretation of Krohe

in Richter v. Vill. of Oak Brook, the Second District determined that a pension board’s

granting of a line of duty disability police pension satisfies the requirement of “a

catastrophic injury” under section 10(a) of PSEBA as a matter of law, even though the

Village was not a party to the pension proceeding.

The Vernon Hills case is on appeal to the Illinois Supreme Court. The briefing is

completed and oral argument was held on May 20, 2015. Until the Supreme Court

resolve this issue, municipalities in the Second District should carefully evaluate the risk

of not intervening in the pension board process. Under the Vernon Hills case, a

municipality will be bound by the pension board determination even though the issues

differ. This is based on the Second District’s interpretation of the language in Krohe

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where the Supreme Court stated that the definition of “a catastrophic injury” is

synonymous with an injury resulting in a line of duty disability pension. See Village of

Vernon Hills v. Heelan, 2014 IL App (2d) 130823 at ¶ 33. Municipalities in other judicial

districts do not face this risk and should likely follow a different path. Until the Supreme

Court decides the Vernon Hills case, uncertainty will continue to exist regarding the

application of collateral estoppel in the nature of the process will depend on the

geographic location where the officer is employed and whether the employer adopts its

own administrative process.

ORDINANCE NO.

AN ORDINANCE AMENDING CHAPTERS __ OF THE

[INSERT MUNICIPALITY] MUNICIPAL CODE (PUBLIC SAFETY EMPLOYEE BENEFITS ACT)

WHEREAS, the Village of X is a home rule municipality in accordance with the

Constitution of the State of Illinois of 1970; and

WHEREAS, the Village pursuant to its home rule powers has authority to adopt ordinances

and to promulgate rules and regulations that pertain to its government and affairs that protect the

public health, safety and welfare of its citizens; and

WHEREAS, the Village, under its home rule authority, and pursuant to Pedersen vs.

Hoffman Estates ( 2014 Il Ap (1st) 123402), has the authority to establish an administrative

procedure for determining claims for benefits under the Public Safety Employee Benefits Act (820

ILCS 320/1 et seq.), subject to judicial review by seeking a common law writ of certiorari; and

WHEREAS, the President and Board of Trustees of the [INSERT MUNICIPALITY] have

adopted the “Public Safety Employee Benefit Act Procedure” by Resolution; and

WHEREAS, as a result of the Illinois Appellate Court decision in Pedersen vs. Hoffman

Estates, the Village now desires to amend its Procedure by deleting the “PSEBA Hearing Process”

and “PSEBA Application Procedure” sections of the Procedure and to adopt the following

procedure and finds that this is in the best interest of the municipality and its citizens.

NOW, THEREFORE, BE IT ORDAINED by the President and Board of Trustees of the

[INSERT MUNICIPALITY], Lake County, Illinois, as follows:

Section 1: That Article ___, ADMINISTRATIVE PROCEDURE TO DETERMINE

ELIGIBILITY UNDER THE PUBLIC SAFETY EMPLOYEE BENEFITS ACT, be and is

created to read as follows:

ARTICLE __

ADMINISTRATIVE PROCEDURE TO DETERMINE ELIGIBILITY UNDER THE

PUBLIC SAFETY EMPLOYEE BENEFITS ACT

Section ____1. PURPOSE

The purpose of this chapter is to provide a fair and efficient method of determining the eligibility of an employee for the benefits enumerated under the Public Safety Employee Benefits Act (“PSEBA”) through an administrative process, including if necessary, an administrative hearing. All benefits provided employees pursuant to PSEBA will be consistent with PSEBA.

Section ____2. APPLICATION PROCEDURE.

A. Public safety employees or family members of an injured or deceased Public Safety Officer in the event the employee is not capable of taking this action (“Applicant”) must file with the Village Manager a full and complete PSEBA application as described in more detail in this Section 2, in writing, within thirty (30) days of filing a pension claim, or within thirty (30) days of the date of the adoption of this Ordinance in the event that an Applicant has filed for a pension claim prior to date of adoption of this Ordinance, whichever is later, if the Applicant is seeking benefits under PSEBA. Failure to timely file the full and complete application with the Village Manager shall result in a forfeiture of the benefits under PSEBA. Upon request, the Village shall furnish a Public Safety Employee Benefit Act Application to the Applicant. PSEBA applications are also available from the Village Manager, Finance Director or on line through the Village’s intranet (HR website).

B. Any Applicant seeking benefits under the Act shall complete the application provided by the Village, and include the public safety employee’s or family member’s firsthand knowledge explaining how the disability injury/death directly resulted from:

i) A police officer’s response to fresh pursuit; ii) A police officer’s response to what is reasonably believed to be an

emergency;

iii) A police officer’s response to an unlawful act perpetrated by another; or

iv) A police officer’s participation during the investigation of a criminal act.

C. The Public Safety Employee Benefit Act Application must be sworn and notarized to certify the truthfulness of the content of the information contained in the completed application, along with a signed PSEBA medical authorization release, and a signed PSEBA general information release. Both the PSEBA medical and PSEBA general information releases authorize the collection of information related to the incident including, but not limited to, the disability pension proceedings, worker’s compensation records and medical records. A review of the Application will not occur until the Application is complete including the medical releases. D. The complete application must include the name of employee, date of hire, detailed information regarding the incident, (including date, time, place, nature of injury, any other factual circumstances surrounding said incident giving rise to said claim), witnesses to the incident, witnesses the Applicant intends to call at the PSEBA hearing, information and supporting pension documentation filed with the Police Pension Board and any Police Pension Board determination or ruling, information supporting the PSEBA eligibility requirements, a signed PSEBA medical authorization release, a PSEBA general information release authorizing the collection of information as set forth in Section C above, and if applicable, other sources of health insurance benefits currently enrolled in or received by the employee and or family members if the employee is deceased. E. The PSEBA medical information release must specify name and address information for pertinent health care provider(s) and hospital(s), along with employee’s and/or his/her authorized representative’s signature and witness signature. F. The PSEBA general information release must specify name and signature of employee or his/her authorized representative along with legal proof of said representation along with name and signature of witness authorizing the collection of information pertinent to the incident review process. G. On the date that the PSEBA application is deemed complete by the Village, the completed application, which will include a completed PSEBA application, PSEBA medical release and PSEBA general information release, shall then be

submitted to the Village Manager, as the Preliminary Record, and a copy of the same shall be date stamped and provided to the Applicant. H. Upon receipt of a complete application for PSEBA benefits timely filed, the Village Manager shall review the Application and supporting documents to make an initial determination as to whether or not an administrative hearing is required to determine whether to:

a. Grant benefits based upon the facts on the application as it stands; b. Set matter for an administrative hearing before a Hearing Officer to make a

determination based on the result of an administrative hearing. c. Enter such other finding as is consistent with the evidence or by agreement

of the Applicant and the Village. I. If the Village Manager grants the benefit based on the Preliminary Record as it stands, the Applicant will be contacted, by the Village Manager’s Office, within thirty (30) days of the decision. The Applicant will be required to contact the Finance Director for benefit explanation and processing. J. If the Village Manager denies the benefit based on the Preliminary Record as it stands, the Applicant will receive written notice of such denial and the Applicant shall have the right to request an administrative hearing which must be served in writing to the Village Manager not later than thirty (30) days after being served with written notice of the denial. Upon receipt of a timely notice from the Applicant, the Village Manager shall schedule an administrative hearing and serve the Applicant with Notice of the Administrative Hearing. K. If the Applicant, upon receiving written notice of denial, chooses not to request an administrative hearing, the Applicant will be required to contact the Finance Director to discuss other options in which the Applicant may be eligible to participate. L. If the Village Manager determines the matter requires an administrative hearing, the Applicant will be given written notice of such decision along with a date for the scheduled administrative hearing. M. If the Applicant, upon receiving written notice of the administrative hearing date, cannot attend said date as indicated in the Notice of Administrative Hearing,

the Applicant must contact the Hearing Officer within seven (7) days after being served with notice of the administrative hearing, communicating alternative hearing date(s) which are within close proximity of the original date indicated by the Hearing Officer. Failure to appear may result in denial of benefits.

Section 3. ADMINISTRATIVE COMPOSITION

The administrative hearing shall be scheduled, which hearing shall be comprised of a hearing officer whose power and authority and limitations are as follows:

A. Power of the Hearing Officer. The hearing officer shall have all of the powers granted to him under common law relative to the conduct of an administrative hearing including the power to:

1) preside over all village hearings involving PSEBA;

2) administer oaths;

3) hear testimony and accept evidence that is relevant to the issue of eligibility under PSEBA;

4) issue subpoenas to secure attendance of witnesses and the production of relevant papers or documents upon the request of the parties or their representatives;

5) rule upon objections in the admissibility of evidence;

6) preserve and authenticate the record of the hearing and all exhibits in evidence introduced at the hearing;

7) issue a determination based on the evidence presented at the hearing, the determination of which shall be in writing and shall include a written finding of fact, decision and order.

B. Hearing Officer. The Mayor with the consent of the Board of Trustees is hereby authorized to appoint a person to hold the position of a hearing officer for each and every individual hearing that shall come before this Village. In making said selection, the Mayor shall consider all pertinent information including, at a minimum:

1) the candidate's ability to comply with the job description as set forth herein;

2) background and performance data made available to the Mayor on file with the Village or otherwise obtained by the Village;

3) the candidate must be an attorney licensed to practice law in the State of Illinois for at least three (3) years and have knowledge of and

experience in employment and labor law, general civil procedure, the rules of evidence, and administrative practice.

Section ____4. PROCEDURE

The system of administrative hearings for determination of eligibility for benefits under PSEBA shall be initiated either by the Village Manager or by an Applicant after the submission of a full and complete PSEBA application as described in more detail in Section 2 requesting the benefits enumerated under PSEBA and requesting the setting of a hearing to determine eligibility to receive said benefits.

Section ____5. ADMINISTRATIVE HEARING

An administrative hearing shall be held to adjudicate and determine whether the Applicant is eligible for benefits under PSEBA. If the Applicant is found eligible, the benefits shall be consistent with the Act

A. Time and date. Hearings shall be held on the date, time and place as established by the Village with appropriate notice served upon the Applicant.

B. Record. The Applicant, at Applicant’s expense, shall ensure that all hearings shall be attended by a certified court reporter and a transcript of all proceedings shall be made by said certified court reporter and a copy be provided to the Village at Applicant’s expense within fourteen (14) days of the date of the PSEBA hearing.

C. Procedures. The Village and the Applicant shall be entitled to representation by counsel at said hearing and may present witnesses, may present testimony and documents, may cross-examine opposing witnesses, and may request the issuance of subpoenas to compel the appearance of relevant witnesses or the production of relevant documents.

D. Evidence. The rules of evidence as set forth in the Illinois Code of Evidence shall apply.

E. Final Determination. The determination by the hearing officer of whether the petitioning Applicant is eligible for the benefits under the Public Safety Employee Benefits Act (820 ILCS 320/1 et seq.) shall constitute a final administrative determination for the purpose of judicial review under the common law writ of certiorari.

F. Burden of Proof. At any administrative hearing the Applicant shall have the obligation and burden of proof to establish that the Applicant is qualified to receive the benefits.

G. Administrative Records. All records pertaining to the administrative process will be held in a separate file in the employee’s name within the Finance Department of the Village.

Section 6: SEVERABILITY.

If any section, paragraph, clause, phrase or part of this ordinance is for any reason held invalid, such decision shall not affect the validity of the remaining provisions of this ordinance, and the application of these provisions to any person or circumstances shall not be affected thereby.

Section 7: CONFLICT.

All ordinances or parts of ordinances in conflict with the provisions of this ordinance are hereby repealed insofar as they conflict herewith.

Section 8: PUBLICATION OF ORDINANCE.

The Village Clerk is authorized to publish this ordinance in pamphlet form.

Section 9: EFFECTIVE DATE.

This Ordinance shall be in full force and effect immediately from and after its passage and approval.

[INSERT MUNICIPALITY]

Application for Benefits under the Public Safety Employee Benefits Act (“PSEBA”)

PLEASE NOTE:

A complete application must be filed with the Village Manager’s office within thirty (30) days of filing a pension claim or within thirty (30) days the date of adoption of Ordinance No. ____ Please provide the following information in as much detail as possible.

1) Applicant Information including

a. Name of Employee or Name of Applicant if not the Employee b. Address, City, State, Zip c. Phone

2) If the applicant is a family member, describe the relationship to the injured or

deceased public safety officer. 3) List Name, Age and Relationship of Spouse and All Dependent Children.

4) Describe the details surrounding the event giving rise to this application,

including but not limited to date, time, place, nature of injury and all other factual circumstances surrounding the incident giving rise to the claim, including witnesses to the incident, other public safety personnel on site, including but not limited to fire district and other police department personnel.

5) List the witnesses that you intend to call in the event that a PSEBA hearing

required.

6) Please describe the nature, extent, date, and circumstances of any previous work related, personal injuries or illness that created any temporary, partial or permanent disability for the public safety officer.

7) Please include the name and address of treating physician(s).

8) Please describe whether you suffer from any preexisting conditions which your

injury aggravated or made worse.

9) Describe preexisting condition.

10) List all treating physicians for any preexisting condition. (name, address, phone number)

11) State whether your disability is a result of your “injury” or whether it results

from a preexisting condition.

12) Has the applicant made any other requests in the past for PSEBA benefits? If so, please explain.

13) Has a line-of-duty disability pension been applied for or granted by the Village’s

Police Pension Fund Board?

a. Applied for: If yes then Date ____ No _____ b. Granted: If yes then Date ____ No _____

14) If so, please provide the date of application or pension and attach copies of any

materials submitted in support of such a pension.

15) List any and all witnesses to the qualifying injury and/or death (include name,

address and phone number).

16) List all physicians who issued reports regarding your application for a line of duty pension application.

17) Describe how the injury directly resulted from: 1) a response to fresh pursuit; 2)

what was reasonably believed to be an emergency; 3) the investigation of a: i) criminal act; or ii) an unlawful act perpetrated by another.

18) Provide any other facts that would qualify you for PSEBA benefits.

19) Are you currently insured under the Village health insurance plan? Yes No.

20) List other current sources of health insurance benefits payable to you. Include

company name, benefit plan, and the cost of any such plan:

Company Name Benefit Plan Cost of Plan

21) Have you gone through an ADA Reasonable Accommodation Hearing process?

Yes No 22) What accommodation did you request?

23) If so, what was the result?

24) On what date did you engage in an interactive dialogue regarding your request

for a “reasonable accommodation”?

PSEBA DISCLOSURE ACKNOWLEDGEMENT To determine eligibility for PSEBA benefits, the [INSERT MUNICIPALITY] and its attorneys may need to review relevant medical records from yourself or the injured public safety officer. Please complete and attach the waiver form to authorize the Village to review medical records. This statement is made for the sole purpose of receiving benefits under the Public Safety Employee Benefits Act from the [INSERT MUNICIPALITY]. The information contained in this application is true to the best of my knowledge and belief. I understand that it is unlawful for a person to willfully and knowingly make, or cause to be made, any false, fraudulent, or misleading oral or written statement to obtain health insurance coverage as provided by the Public Safety Employee Benefits Act. 820 ILCS 320/10(a)(3). Any omission of information related to this application could constitute a basis for denial. Such actions constitute a Class A Misdemeanor and can serve as the basis for denial or forfeiture of any benefits paid out under the Public Safety Employee Benefits Act. I understand the terms of the [INSERT MUNICIPALITY] PSEBA policy and PSEBA procedure. I specifically understand that my PSEBA benefits will include enrollment in the Village’s HMO health plan, or any alternative basic plan that the Village may substitute from time to time. I certify the truthfulness of the content of the information contained in the attached application. I further certify that this application is complete and I am not aware of any additional information that is relevant to this matter. Name and Signature of Applicant Date: ___________________________ ____________________ State of Illinois ) County of ____) I, ___________________, a Notary Public, in and for the County and State aforesaid, do hereby certify that _____________, personally known to me to be the same person whose name is subscribed to the foregoing instrument, appeared before me this day in person and acknowledged that he/she signed and delivered the same instrument as his/her own free and voluntary act for the uses and purposes therein set forth. Given under my hand and Notarial Seal this ________ day of _________, 20___

____________________________ Notary Public

Medical Information Release (Required for each health care provider)

To: And: I hereby authorize my physician, physical therapist, and any and all other health care providers, as well as the institution(s) with which they are affiliated, to release to the [INSERT MUNICIPALITY] and/or its representatives any and all medical records or other medical information (including but not limited to medical or mental health records, reports, x-rays, photographs, notes, bills, payment schedules, prescriptions, insurance records or claim forms) which relate in any way to my ability to perform the essential duties of a Public Safety Officer with the Village as well as my eligibility for benefits under the Public Safety Employee Benefits Act. The above described medical records and information should be released to the Finance Director of the [INSERT MUNICIPALITY], or any other authorized Village representative. This request specifically includes the release of any records relating to my current or past mental health status as deemed relevant by the Village, so that the Village may assess my qualification for benefits under the Public Safety Employee Benefits Act. I understand that by releasing these records, I am waiving any rights I might have under the Illinois Mental Health and Developmental Disabilities Confidentiality Act (“HIPPA”), which governs disclosure of certain confidential mental health information. I understand that if I refuse to consent to disclose these records, the Village may proceed with determining my eligibility for benefits under the Public Safety Employee Benefits Act based on only what information it has currently. This consent will expire one year from the date next to my signature, unless I revoke it earlier, in writing, signed by a witness. I understand I am waiving any rights I may have under HIPPA for any disclosure made prior to a revocation. I understand any such revocation will not be effective until delivered to the health care providers listed above and will not affect any prior release of information. I understand I may ask to inspect and/or copy the records which are being released. Name: __________________________ Date: ________________ State of Illinois ) County of ____) I, ___________________, a Notary Public, in and for the County and State aforesaid, do hereby certify that _____________, as _____________ of ________, personally known to me to be the same person whose name is subscribed to the foregoing instrument, appeared before me this day in person and acknowledged that he signed and delivered the same instrument as his own free and voluntary act and as the free and voluntary act of ______, for the uses and purposes therein set forth. Given under my hand and Notarial Seal this ________ day of _________, 20___

________________________________ Notary Public

[INSERT MUNICIPALITY]

Public Safety Employee Benefit Act Procedure

Introduction The Public Safety Employee Benefit Act (PSEBA) allows for public safety employees, who suffer a “catastrophic injury” in the line of duty, the opportunity to apply for the Village’s base health insurance coverage paid at 100% for the employee for the rest of the disabled employee’s life and his or her qualified dependents for a period of time defined by the Act. The PSEBA also allows for the qualified spouse and/or qualified dependent(s), who were granted a surviving spouse/dependent person, due to a duty related death of a public safety employee, the same opportunity to apply for the Village’s base health insurance plan paid at 100%, for the period of time defined by the Act for both the surviving spouse or qualified dependent. Until processing and acceptance of the Public Safety Employee Benefit is completed, the applicant may remain on the Village’s health insurance plan (either HMO or PPO plan), however, they will be responsible for paying 100% of the insurance premium cost. Health insurance premiums must be paid by the last day of the month for each month’s coverage during the PSEBA review process. Once the application is reviewed, and if the benefit is awarded, the employee may be reimbursed any premiums paid within 60 calendar days of the award date. This reimbursement would be for premiums paid from the official date of death or disability, through the official date of the PSEBA award. If the PSEBA benefit is not awarded, the applicant may continue to remain on the Village’s health insurance plan, however, they will be responsible to pay 100% of the health insurance premium cost. If the applicant chooses not to remain on the Village’s health insurance plan, they will be eligible to continue health coverage under applicable laws as defined by COBRA. To review the Village PSEBA application process and procedural requirements, please review Village Ordinance No. which can also be found in Chapter , Article of the Village Municipal Code, and are available from the Village Manager or Finance Director.

HUNT & _______________________________________________________________________ ASSOCIATES, P.C. ATTORNEYS AT LAW

Three First National Plaza • Suite 2100 • Chicago, Illinois 60602 • Telephone: 312/558-1300 • Facsimile: 312/558-9911

Keith L. Hunt

Keith L. Hunt is the founder and sole shareholder of Hunt & Associates, P.C. He comes from a family of entrepreneurs and practiced with the law firms of Hinshaw & Culbertson, and Niro, Scavone, Haller & Niro, before successfully starting his own practice in 1991. Mr. Hunt is admitted to practice in the State of Illinois, and the Eastern District of Michigan, the Northern District of Illinois (Trial Bar) and the United States Courts of Appeal for the Fifth and Seventh Circuits. Mr. Hunt has been admitted pro hac vice in approximately fifteen district courts throughout the country. Education 1985 - Juris Doctor, with High Distinction (Magna Cum Laude) The John Marshall Law School (Top 3% of class). 1984-1985 - Served as an Editor to The John Marshall Law Review. 1983-1985 - Recipient of Faculty Scholarship. Represented the school in four national moot court competitions. 1983-1984 - University of Chicago, Graduate Economics Program. 1982 - Bachelor in Arts, Economics, State University of New York at Albany. 1980 - Associate in Arts, Orange County Community College, Middletown, New York Consulting CBS “The Good Wife” (2011, 2013 & 2014). Consultant regarding Labor & Employment issues for current season episodes. Articles & Publications K.L. Hunt & S. Levee, When Does “;o” [a wink] Become Offensive: Workplace Harassment in a Textual Revolution, The Docket, September 2010. K.L. Hunt & S. Levee, Layoffs and Downsizing: Economic Necessity or Pretext for Discrimination, Lake County Bar Journal, The Docket, September 2009. T.J. Haller & K.L. Hunt, "Protecting Profits, Goodwill & The Corporate Image," Crain's Chicago Business (1989). Reviewed Intellectual Property chapters in Drafting Employment Agreements (Bender, 1993).Consultant to Matthew Bender in various Labor, Employment and Intellectual Property publications.

Speeches & Seminars Mr. Hunt regularly speaks on topics relating to the firm’s practice areas, including the following partial list: Guest lecturer, Saint Mary’s College at Notre Dame, “Sexual Harassment and Women’s Workplace Issues”, Fall 2014. Speaker, “Illinois Employment Law Update” Lake County Bar Association Employment Law Committee Spring Seminar,(April 2014). Speaker, “Workplace Privacy Issues & Social Media in the Workplace”, LCBA Labor & Employment Law Committee, September 19, 2012, Lake Forest, Illinois. Speaker, “Cyberbullying”, LCBA Diversity Seminar, November 8, 2011, Waukegan, Illinois. Speaker, “Textual Harassment” LCBA Civil Trial Seminar, May 2010, Biltmore County Club, Illinois. Speaker, “Significant Developments in Employment Law”, Lake County Bar Association, May 25, 2008, Lake Geneva, Wisconsin. Speaker, “Current Topics in Employment Law”, LCBA Civil Trial Seminar, May 2004, Lake Geneva, Wisconsin. Speaker, “Class Action Settlements: Ford Motor Company”, Chicago Bar Association, Labor and Employment Committee, November 14, 2001. Speaker, “Racial Profiling”, ATLA Convention, Montreal Canada, July 18, 2001. Speaker, “Racial Profiling and Using Evidence From Outside the Workplace to Prove a Hostile Work Environment”, Chicago Bar Association, Civil Rights Committee, January 17, 2001. Speaker, “Racial Profiling”, Latinos United Comprehensive Advocacy on Fairness in Housing, October 12, 2000. Speaker, Greater O'Hare Association (Chamber of Commerce) Seminar on Human Resource Issues, "Employer Liability Beyond Title VII" and "Sexual Harassment", September 20, 1996. Speaker, Greater O'Hare Association (Chamber of Commerce) Owners' Roundtable, "Recognizing and Dealing With Employment Issues in Small and Medium Sized Business: Avoiding the Pitfalls and Traps," March 31, 1996.

Speaker at seminar on "Current Employment Law Topics," Chicago Bar Association, Labor Employment Committee Young Lawyers Division, February, 1996. Speaker on "Sexual Harassment" Illinois State Bar Association Labor and Employment Committee seminar, Fall, 1996. Lecturer, National Business Institute Seminar (all day) covering "Americans With Disabilities Act", "Sexual Harassment", "Using of Employee Handbooks and Policy Manuals", and "Defending Employment Litigation." Elk Grove Village, Illinois, July, 1994. Speaker, Illinois Dental Hygienists Society, "Dental Malpractice & Insurance Coverage: Current Issues & Topics", May, 1989. Guest Lecturer, The John Marshall Law School, Civil Procedure and Lawyering Process Course, "Legal Malpractice and Rule 11", Fall 1987. Guest Lecturer, Prairie State College Dental Hygiene Program, "The Illinois Dental Practice Act & Dental Malpractice", Spring, 1987. Lecturer, South Suburban Dental Hygiene Association, "Dental Malpractice and the AIDS Crisis: Liability for Refusal to Treat", September, 1987. News Sources Quoted in Chicago Daily Law Bulletin regarding highly publicized sexual harassment and discrimination claims. Quoted in Illinois Employment Law Report, January 1996, in feature article "Bill Gives Bosses Okay to Eavesdrop on Workers Again." Quoted in Chicago Daily Law Bulletin regarding defense of case resulting in significant limitation on EEOC's authority to bring suits against employers. Significant Cases Lorenzen v. OakBrook Investments, breach of employment agreement where employer terminated employment agreement shortly before equity vested. Court awarded $794,000 in back wages, commissions and value of equity interest. Roberts v. Cook County, Sexual harassment trial involving former Deputy Director of Secret Service and former Cook County Inspector General – jury trial – Verdict of $500,000 ($100,000 compensatory and $400,000 punitive). L'Heureux v. Cary Fire Protection District Multi-plaintiff sexual harassment, discrimination and retaliation claims by current and former firefighter/paramedic resulting in adoption of new harassment, hiring, testing and other policies.

Martinez v. Village of Mount Prospect, 96 C 6027 (N.D. Ill. 2000) Medrano v. Village of Mount Prospect, 98 C 4638 and Moser v. Village of Mount Prospect, 98 C 7580 Multiple cases related to racial harassment, discrimination and retaliation including allegations of racial profiling by police department resulting in jury verdict of $1.2 million (for Martinez) – largest reported award for individual liability against governmental officials and first known racial profiling verdict in United States. Warnell v. Ford Motor Company, 1998 WL 748328 (N.D. Ill 1998) Class action case, including 14 named plaintiffs, against two Chicago area plants for sexual and racial harassment and discrimination. Class of more than 1,000 potential claimants resulting in a settlement of $12 Million Dollars. Conway v. Cook County Sheriff: Sexual harassment and retaliation claims by female civilian employees against high ranking Sheriff's Office official with whom plaintiff had a four year consensual relationship. Resulted in significant settlement and eventual removal of harasser. Mendoza v. Mid-American Elevator, 98 C 2917 (N.D. Ill. 2000) Age and retaliation allegations by a bargaining unit employee. Fondrliak v. Commonwealth Edison, 98 C 5985 (N.D. Ill.) Nuclear whistleblower case filed after utility removed plaintiff from position for having complained about nuclear safety violations; upon reassignment, plaintiff was sexually harassed at new job assignment. Welsh v. Commonwealth Edison, U.S. Department of Labor 1998 Six-plaintiff nuclear whistleblower case arising out of removal of employees from positions in utility after they complained about safety violations to the Nuclear Regulatory Commission (NRC) resulting in the largest fine ever imposed against a utility. Rivera v. Ford Motor Company, 95 C 9759 (N.D.Ill. 1997) Nine-plaintiff case involving allegations of a pattern and practice of sexual harassment, hostile working environment and race discrimination at Chicago area manufacturing facility. EEOC v. Walner, No. 95-3524, 1996 U.S. App. LEXIS 18865 (July 31, 1996) Class action suit filed against prominent Chicago area personal injury law firm alleging hostile and discriminatory work environment. Schneider v. Northwestern University, 925 F. Supp. 1347 (N.D. Ill. 1996) Nine-week bench trial involving claims of denial of tenure to university professor due to sex discrimination. Gorence v. Eagle Foods Inc., No. 93 C 4862 (N.D. Ill. 1995) Multiple plaintiff age, sex and retaliation claims filed as class action against Midwest grocery chain involving promotion and compensation issues.

Janopoulos v. Walner, 1996 U.S. Dist. LEXIS 3157 (N.D. Ill. 1996) Sexual harassment and discrimination claims against prominent Chicago personal injury law firm. Zoltek v. Safelite Glass Corp., 884 F. Supp. 283 (N.D. Ill. 1995) Fair Labor Standards Act case on behalf of several workers alleging violation of the overtime requirements of FLSA