AVAILABLE (MS WORD)
AVAILABLE (MS EXCEL)
PRINTED ON LEGAL SIZE (8 1/2" x 14") PAPER.
This form is used to
report all members at the beginning of each year and to report
new members as they join the department during the year. In
the proper columns, it should contain the social security
numbers, names, date of birth, gender, and amount of money for each
member reported. All lists should be in alphabetical order by
municipality and not by individual stations within a
municipality. Please send the original form to the
State Board on 14 inch paper and save the completed form in
the computer and a paper copy in a file for future
Report Card ON-LINE
If you do not receive a letter from us confirming that we
have received the accident report card, please call our
office! If we have no record of the accident being reported
within 90 days, we can not process bills for payment.
This card is supplied in
order to facilitate quick reporting of all injuries sustained
during performance of duty. It is recommended that a supply be
on hand in each station and that one be completed and sent in
immediately following any injury, no matter how minor it
appears. In the event that the post office should lose the
card, the stub should be filled out and retained by the
department as proof of mailing. All accidents must be reported
to the State Board in writing within 90 days of occurrence or
no claims can be paid by the State Board.
of Accident #5580 DOWNLOAD
PRINTED ON LEGAL SIZE (8 1/2" x 14") PAPER.
This form must be
completed before any claims resulting from an accident can be
paid by the State Board. All sections must be filled out and
signed. A signed emergency room report may be attached in
place of the doctor’s report.
AVAILABLE (MS WORD)
This form is used to
request all payments from the Volunteer Firefighters’ and
Reserve Officers’ Relief and Pension Fund. The name of the
person or firm to receive payment must appear in the box at
the top left. The member should be named and the description
section should list the amount granted and the reason for the
claim (disability compensation, physician’s services,
hospital services, reimbursement for..., refund fees, etc.).
Any bills, physicians’ reports or receipts should be
attached. In the case of payment due to the death of a member,
a photocopy of the death certificate must be attached. A
separate voucher must be filled out for each claimant.
Original bills may substitute for the signature of the payee
for medical claims. All other claims must be signed by the
payee and all claims must be approved by the local board of
trustees before being submitted to the state board for
of Physical Examination
AVAILABLE (MS WORD) This document will print on 8
1/2" X 11" paper.
AVAILABLE (MS WORD) This document will print on 11" X
This form is a sample
of the minimum physical examination recommended by the State
Board for new members. The State Board will pay one hundred dollars toward each physical examination performed when the invoice
voucher requesting payment and the proof of such exam is
received. Because of confidentiality concerns, this form is
not to be returned to the State Board.
retirement forms will be sent to the department or the
retiring member by the State Board upon request. The
Certificate of Eligibility must be completed and approved by
the Local Board of Trustees and the Notice of Retirement must
be completed by the member with his or her signature
notarized. After both forms are returned to the State Board,
the retiree will be placed on the payroll as soon as she or he
is eligible to begin receiving a pension.
retirees to have their pension deposited directly to their
banking accounts. A form to activate this option will be sent
with retirement forms.
Introduction to BVFF - DOWNLOAD
departments are welcome to use this form to send to billing
departments of local doctors, clinics, and/or hospitals to
properly introduce the process of submitting claims. This will
let them know not to send claims to L&I, which
department they should send the claims to, and that claims
will be audited according to L&I fee schedules.
Request Letter - DOWNLOAD
can be used by the local board of trustees to request reports
and chart notes from medical providers. Medical records may
need to be requested to determine the validity of injury
links can be used to search for CPT codes:
can be used to search for diagnosis codes:
of Relief & Pension Act - DOWNLOAD
This download gives a brief
description of the benefits available from the Board for
Volunteer Firefighters & Reserve Officers.
Tables - DOWNLOAD
These conversion tables can
be used to figure out the monthly payment for retired volunteers.
Form - DOWNLOAD
This form must be completed
by a representative at the pensioner's bank. Please be
sure to indicate whether the account is checking or savings. A
check will be sent the first month after the information was
entered along with a letter asking the pensioner to verify
that the account information is correct. If it is not, contact
the Board for Volunteer Firefighters as soon as possible,
otherwise, all future payments will deposit automatically.
Military Service Credit Request Form - DOWNLOAD
with Federal law, Title 38, Part III, Chapter 43, Subchapter
II, Section 4318, the BVFF & RO will allow service credit
to be granted and pension payments to be made up in instances
of interruptive military service for members who must
interrupt their volunteer fire or reserve officer duties to
provide protection for the nation in times of crisis when they
are called to active duty military status. The Board adopts
the following procedures regarding interruptive Military
All eligible members, as defined below, must complete the
Board's Interruptive Military Service Request Form and submit
it within five (5) years of said military service.
Additionally, fire departments shall notify the Board, in
writing, when a member exits service due to a military call
up, and when a member returns to employment. This notification
shall take place within 30 days of the respective
have service in the Army, Navy, Air Force, Marine Corps,
Coast Guard, National Guard, or their reserve units.
apply for reemployment with the employer who employed the
member prior to the member's call-up within 90 days of the
member's honorable discharge, unless the time deployed was:
or less: the employee must report to the employer no
later than the beginning of the first regularly
scheduled work day/drill/meeting (whichever is first)
following the completion of military service
than 30 days, but less than 181: the employee must
submit for reemployment within 14 days, or within a
reasonable time if the employee is not at fault
than 181 days: the employee must submit for reemployment
within 90 days if the employee is hospitalized as a
result of his/her military service, (s)he has a maximum
of two years to recover before submitting for
3. Must be
part of a Title 10 Call-up as noted on a DD214 and NGB22,
which must be provided to the BVFF & RO.
employer (fire or law enforcement department) must notify
the BVFF & RO within 30 days of the member's
member must apply to receive the credit, using the
appropriate form, and pay the prescribed fees within five
(5) years of returning to employment.
Board shall establish the member's service credit and bill the
employer for its contribution required under RCW 41.24 for the
period of military service, plus interest based upon the
documentation received with the member's application form.
must pay his/her portion of the fees, unless the employer has
elected to make the member's payments for the other members of
may not make payments in excess of a five (5) year cumulative
period of service.
must be submitted with documentary evidence when proving
service for a member.
Participation Requirement Exemption Request Form -
submitted, this form will be presented at the next scheduled
meeting of the State Board. Please inquire after that date
Retire/Rehire Physical Examination Certification -
will need to be submitted annually for retirees who rejoin the
department while collecting a retirement pension. Please find
the amount of the next year's disability fee in the annual
letter sent toward the end of the year regarding annual fees.
Pain Management Policy - DOWNLOAD
Documentary Evidence Checklist Directions - DOWNLOAD
Documentary Evidence Checklist - DOWNLOAD
This checklist will be required when submitting documentary evidence to prove volunteer firefighter or reserve office service.
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