2003-11-03 - Firefighter Pension Board - Agenda Packet /' _
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BUFFALO GROVE FIRE DEPARTMENT
FIREFIGHTER'S PENSION FUND
REGULAR
MEETING NOTICE
Date:November 3, 2003
Fire Administrative Headquarters
1051 Highland Grove Drive
Buffalo Grove, Il 60089
5:30 P.M.
1. Call to Order
2. Roll Call
3. Approval of Minutes,Meeting of Apri17, 2003
4. Financial R'eport:
a.)Mesirow on status of the fund
5. Old Business:
a.)Report on expenditures
6. Other Business:
A.) Adopt revision of form"M"
B.) Request for a Survivors pension
C.) Acceptance of 2 new members
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5. Adjournment: � `
Note: Dinner will be provided for the Board 1Vlembers
The Village of Buffalo Grove, in compliance with the
Americans With Disabilities Act, requests that persons with
disabilities who require certain accommodations to allow
them to observe and/or participate in this meeting or have
questions about the accessibility of the meeting or
facilities contact the ADA Coordinator at 459-2518 to allow
the Village to make reasonable accommodations for those
persons .
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FORM M
BUFFALO GROVE FIREFIGHTERS' PENSION FUND
APPLICATION FOR WIDOWNVIDOWER AND/OR DEPENDENT BENEFITS
� '�� "� '�"J �����'��_�, am the legal wife/husband of the deceased
and/or the legal dependents of the deceased,��C� ��� _—c��\
Date of death:���"���� ��� � ����
I hereby make application for the following type of widow/widower and/or dependent pension from
the Buffalo Grove Firefighters' Pension Fund:
, regular surviving spouse benefits(40 ILCS 5/4-114(a))
� minor and/or sunriving children benefits(40 ILCS 5/4-114(a))
duty-related surviving spouse benefits(40 ILCS 5/4-114(i))
LNING STATUS
Were you living with the deceased at the time of death? Yes � No
If no, please state your address and phone number:
Address:
Phone Number.
Reason for not living with the deceased(indicate separatio�or divorce,or explain other reasons):
Residence of deceased at time of death: � - ���--���`�+��-�--Z �
���-�y�-t��� ��
Phone Number. �
Indicate whether the deceased was an active or retired firefighter or receiving disability benefits at
the time of his or her death:
Active �,_ Retired Receiving Disability Benefits
NATURE OF DEATH
1. If active,was the deceased on duty at the time of his or her death? Yes No �
2. Cause of death (please attach copy of death certificate):,� `1�� c� c3 �.
3. Was an officiaf inquiry as to the cause of death made? Yes � No
If yes, one copy of the verdict of finding, duly certified, must be attached to this application.
��� �'3�C����'Cl�\S G�c\C�
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4. Did the deceased die as a result of sickness, accident, or injury incurred in or resulting from
the performance of an act of duty or from the cumulative effects of acts of duty as set forth
in Section 4-114(i)of the Illinois Pension Code(40 ILCS 5/4-114(i))? �-
Yes No �`ll��.{�C,���.�
5. Was the de eased under physician's care at any time during the last twelve(12)months?
Yes � No If yes, please give the name, address and phone
number of the physician(s): ���`
Name of Physician:�,
Address: ✓ � � �' � `�-
Phone Number:
��"1-��\-u`b�l� �Bu��-� ����, � ��
Name of Physician:��_�\1c�1 �"\��`(l�
Address:� i ��C�\�f`C��;�C�����
Phone Number. �y�•-- �.,.�"�—���
Name of Physician:
Address:
Phone Number:
DEPENDENTS OF DECEASED
Are there any dependent (natural or adopted) children or parents that are entitled to pension
benefits from this Fund? Yes �_ No Are there any children that have been
conceived but not yet born? Yes�_ No If yes, please indicate the expected date of
birth: �b
Are there any dependent (natural or adopted) children who are over the age of 18 and are
dependent by reason of a physical or mental disability? Yes No�If yes, please list
the names, dates of birth, place of birth, and indicate in the case of children whether the children
are natural or adopted. Also attach copies of birth certificates and/or adoption papers, duly certified.
If the child is dependent by reason of a physical or mental disability, please attach a certified copy of
the court's order adjudicating the child as a disabled person pursuant to Article Xla of the Probate
Actof 1975(755 ILCS 5/11a-1 etseq.).
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DATE PLACE NATURAL
NAME OF BIRTH OF BIRTH SOCIAL SECURITY NO. RELATIONSHIP or
ADOPTED
--�-���c �.��� �-��a�� A�������� 3�s-�����'��
c� - �����cc�
1�\� �(`(�� �- ��-.��c�c, c��,� --�-v����.
I certify that the above information and statements are true and correct to the best of my
ability. ,
Applicant's Signature�:a����.�--�C�\
Date: `�����CR'��
SUBSCRIBED and SWORN to before me
this_day of ,
Notary Public
FOR BOARD USE ONLY
The foregoing application having been duly presented and considered by the Board of
Trustees of the Buffalo Grove Firefighters' Pension Fund, the same is hereby
' Approved/Rejected(circle one)this
day of ,
BOARD OF TRUSTEES OF THE BUFFALO
GROVE
FIREFIGHTERS'PENSION FUND
By:
President
By:
Secretary
Revised 10/15/03
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I HEREBY CERTIFY THAT the ioregoing is a true and correct copy of the death record for the decedent named at item l,and that this
record a�a tablis d a filc3 in my ofiice in accordance w�ith the pro�isions of the Illinois Vital Records Act.
� ville Illinois on October , 2003
• at Liberty ,
Stevcn C.Noble� Registrar Date
The original neord o[this death i�permanendy filed with the ILLINOIS DEPARTMENT OF PUBLIC I�iFALTH at SpringCeld. County clerl:s and loul
rzgisdars are authorized to mal•e eertificatioas from eopies otthe original reeotd. Tha Illinois slawte:pmvide that tbe certifiution of a death rewrd
by the Department o[Public He�lth.locai ngistnr or eounry eterl'shall bo prima ficie evidence in all eourts and places oT the ficts therin sutod.
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. . Bt�ffa�a �C'�rov�e-F�ire�ghxers-P�e�sion Fund
Sp.�c�a� l�!�eeting
Ap��� 7, 2.003
105 � ��ig��a�d.���G��ve �r�ve
B���a.�o ,����e, I�l�o�s
Members Present: President J. Wieser, Secretary T. Shurba, E. Hartstein, Chief
T. Sashko, T Gough , M. Anders�n, W. Raysa, J. Tenerelli.
Members Absent: J. Sirabian
Guests: Scott Anderson, from the Village of Buffalo Grove and Carolyn Welch
Clifford, and Bob Trevarthen from OTBK&C, Ltd.
Meeting called to order at 18:05
Motion to accept the minutes of March 17, 2003 made by Raysa, seconded by
Sashko, Motion carries
Discussion on the taping of minutes. It was decided that since the reason for
taping the meeting was to help the secretary in typing minutes, there was no reason
to keep the tapes.
Decision to table the financial portion of the meeting so old business including Lt.
Deau's Finding and Decisi�n, also the_Boards draft�et of rules.
Motion to accept the final draft of the Findings and Decision of Lt. Robert Deau's
Disability Hearing and by Sashko seconded by G�ugh Roll Ca11 taken
AYES : President J. Wies�r, E. Hartstein, Chief T. Sashko, T Gough, M.
Anderson, W. Raysa,J. Tenerelli
Nays: None.
ABSTAIN: None
ABSENT: Secretary T. Shurba. J. Sirabian
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Motion Carries
President Wieser will send a_certifi�d letter t�.Lt.Deau with The Finding and
Decision.
Discussion on the Villages rights after a decision of the Pension Board.
Discussion on depositions of IlVIE's for the Calibraro case.
Motion made by Sashko to all�w Mr.Duda.at his clients expense to run a
deposition with the da.te and time to be determined later so the pension board's
attomey and any board member that w�uld like to attend can be there. Second by
Raysa.
Motion carries.
Carolyn suggested that we get_Mr. Duda to_sign that he would a11ow the doct�rs
reports to be released for the boards review.
Discussion on draft set of rules, all the forms at the end.
Discussion on whether existing employees need to fill out new forms, it was
decided not necessary.
Discussion on changing the wording in form C from "Does the firefighter suffer
from ect." To "Does the firefighter �3emonstrate any impairment caused by ect."
On form K change "resignation leiter"to "r�tir�ment_re.quest" in middle of page.
Motion to accept the rules as amended made by Sashko seconded by Gough.
Roll ca�l.�aken.
AYES: President J. Wieser, Secretary T. Shurba, Chief T. Sashko, T Gough , M.
Anderson, W. Raysa, J. Tenerelli.
Nays: None
ABSENT: E. Hartstein, J. Sirabian.
Motioq�arries �
A suggestion to distribute a copy of these rul�s to a11 fire station.
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President Wieser wanted to adviss board�n expenses in the„past few months.
� 14, 1�10.08 for the Deau hearing.
6344.55 on the Calibraro case
1, 7S 1.90 Board expenses.
He will break down these figures into a warrant type format in a future meeting
Motion to adjoura made by Gough second by Anderson
Motion carries at 19:17 �
Submitted April 19, 2003
By Tony Shurba
Approved by Board on , 2003
President Joe Wieser
Secretary Tony Shurba