Utilization of Sick and Annual Leave for Peace Officers (SORM80-PO)
Employee's Election Regarding Utilization of
Sick and Annual Leave (SORM 80-PO) for Peace Officers
* NOTE: These forms are in Adobe Acrobat format. You must
have the free Adobe
Acrobat Reader to access the forms.
Purpose of Form:
Injured employees must choose whether to utilize accrued sick
leave, annual leave or injury leave before receiving
workers' compensation income benefits.
Filing Deadline:
The form must be received by SORM not later than the 5th
calendar day after the first full day of lost time
has occurred. If not received by that date,
the employee will be paid under Election II - to use
no accrued leave time. This election cannot be modified
once implemented.
Completed by:
The claims coordinator and injured employee.
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Instructions:
1. The Claims Coordinator will enter employee's name, social
security number, agency and claimant's date of injury in the
spaces provided.
2. The Claims Coordinator will explain to the employee the
differences in the election options so that the employee can
make an informed decision. After the employee makes the decision
and signs the form, the form cannot be altered after the employee's
8th day of disability. The reason for this is that it will
affect how the benefits are paid and could result in an overpayment
that the employee could possibly have to pay back to SORM
or might result in an underpayment of benefits owed.
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Election 1:
choose one |
This option uses all accrued sick leave prior to
receiving workers compensation benefits if owed.
Three options of Election 1 are presented. The employee must
choose one of the options.
Election 1A - When the employee
loses time from work due to the compensable injury or illness,
the employee chooses to use all accrued sick and annual
leave until it is exhausted, before receiving any
workers' compensation benefits. This means the employee will
stay on the payroll until his/her sick and authorized annual
leave is exhausted. This also means that if the claimant returns
to work and then has additional days of disability, all additional
sick and vacation leave accrued will be exhausted before receiving
any additional workers compensation benefits.
This also means that if the employee is out for an extended
period for a serious illness and then returns to work, then
there will be no sick or annual leave to use in case additional
medical treatments are required.
Election 1B - this election states
that the employee chooses to use all of his/her accrued
sick and a portion of annual leave. The employee
chooses how much annual leave he/she wants to use and the
employee will stay on the payroll for as long as his/her sick
and annual leave will cover. This also means that if the claimant
returns to work and then has additional days of disability,
all additional sick leave accrued and balance of authorized
annual leave if any will be exhausted before receiving any
additional workers compensation benefits.
Election 1C - this election states
that the employee chooses to use all of his/her accrued
sick leave and NONE of his/her accrued
annual leave. This means the employee will stay on the payroll
until his/her sick leave is exhausted. This also means that
if the claimant returns to work and then has additional days
of disability, all additional sick leave accrued will be exhausted
before receiving any additional workers compensation benefits.
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OR choose
Election 2 |
This election states that when the employee loses time
from work, he/she elects to use none of the
accrued sick leave and none of the accrued
annual leave. This means the employee will be automatically
placed into a leave with out pay status when he/she loses
time from work. The first 7 days of disability is called the
7 day waiting period. Workers compensation income benefits,
if owed, will not start until the 8th day of disability. If
the employee returns to work and then has additional days
of disability, the employee will return to leave without pay
status. The waiting period will be paid after the employee
has been unable to work for a total of 14 days.
This is also the default election. If the SORM 80-PO is not
received within 5 days after the first day of disability,
this is the option that will be used. If the form is received
later than the 5th day, the form will not be accepted. The
employee will have to stay with Election 2 throughout the
life of the claim. There will be no exceptions.
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3. If the employee elects any of the Option 1
choices, the claims coordinator must enter the number of sick
leave hours and annual leave hours available in the spaces provided.
The form will be rejected if the hours are not filled in.
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OR choose
Election 4 |
This election states that they employee wishes to be placed
on injury leave. This means that they will stay on the payroll
until injury leave is exhausted. Temporary income benefits,
if owed, will begin at the exhaustion of injury leave. Injury
leave will exhaust one year from date of injury. |
Distribution:
4. The claims coordinator will fax a copy of the original to
the State Office of Risk Management.
5. The claims coordinator will retain the original in the
agency files.
NOTE: The claims coordinator must notify SORM via
the SORM-90 within 2 calendar days of the expiration of the
elected leave. This will ensure that benefits are paid timely.
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