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ACTION AGENDA
Board of Trustees of the Employees ' Pension Fund
May 1 , 1, 996 ;
1. :Call to order 1. 9:24 a.m.
•; 2. '. Approval of Minutes ' 2. Approved as submitted..
of 4117195 ,
3. Request.for acceptance. 3. Approved.
into membership:
a) Janice.P. McLaughlin
b) James Johnson, Jr.
c} Michael Roza
dI Roy B. Wilson
.4. ' Regular Pension to be granted: 4. Granted.
Norma, F. Smith
' 5. Regular Pension to be granted: 5. Granted.
• Robert E. Morrison
6. Job-Connected Disability Pension 6. Granted.
to be granted:
Michael J. Szuba
• 7. Other Business: 7. Deputy City Manager Rice
announced the unions have'
reached a contract settlement and
that the pension fund will pay
' some of the cost.
8. Adjournment: 8. 9:27 a.m.
M
''? TRUSTEES OF THE EMPLOYEES' PENSION FUND Item #
' Agenda Cover r Memorandum Meeting Date: 5LJ 190
Subject:
Membership in Employees' Pension Platt
Recommendation/Motion:
Employee(s) listed below be accepted into the Employees' Pension Plan as recommended by the
Pension Advisory Committee.
? and that the appropriate officials be authorized to execute same.
BACKGROUND.
Seniority Pension
Depi.lDJv. IZ S.? EffegliYe 12gle
Janice P. McLaughlin, Staff Assistant II Gas 4/3/95 4/3/95
James Johnson, Jr., Utilities Mechanic I Engineering/WPC 3120195 3120/95
Michael Roza, Networking Tech. Supv. Police 413195 413195
Roy B. Wilson, CAD Technician Engineering 413195 413/95
Reviewed by: Originating Dept: oats: Commission Action:
Human Resourc Total
Legal NA ? Approved
Budget NA
Purchasing NA
User Dept.:
Current FY ? Approved w/conditions
? Denied .
Risk Mgmt. MA __ ? Continued to:
CIS Funding Source;
ACM _ Advertised: ? Capt. Imp.
Other NA Date: ? Operating
Paper: ? Other Attachments:
4 Not required
Submitted by Affected parties
? Notified Appropriation Code: Letter(s)
M Not required ? None
City Manager
V
CITY OF CLEARWATER
EMPLOYEES' PENSION PLAN
PENSION ADVISORY COMMITTEE
' TO:, Pension Trustees
' FROM: Pension Advisory 'Committee
SUBJECT: Recommendation' for Acceptance into Pension Plan
DATE; April '5, 1995
As Trustees of the City. of Clearwater Employees' Pension Fund, you are hereby notified that the
employee(s) listed below have been duly examined by . a local physician and each has been
designated as a "first class risk". '
These employees 'are eligible for pension membership as noted in the Pension Eligibility Date '
column, bclo'w, and it is the recommendation of the Pension' Advisory Committee that they be
accepted into' membership.
Pension Elig.
NUme. Job._CIas-,, & DeR,/piv. Birth_Wtg Hire _D&tS;"
Janice P. McLaughlin, SS#369-46-8989
Staff Asst, II, Gus System 3/10145 413195 4/3/95
James Johnson, Jr., SS4243-64-5793 114144 3/20/95 3/20/95
Utilities Mechanic 1, Engineering/WPC
Michael Roza, SS#065-44-0544 7/26/51 413195 413195
Networking Tech. Supervisor, Police Dept.
Roy B. Wilson, SS#366-92-2244
CAD Technician, Engineering Dept, 10/14/67 413/95 4/3/95
k
ra
TRUSTEES OF THE EMPLOYEES' PENSION FUND Ilom #
Agenda Cover Memorandum Meeting Date: X LI / E 5
' ? iwwwwwrwm?rrmrrr?ninni?rrrrr?rr?
Subject:
Pension to be Granted:
Recommendation/Motion:
Norma F. Smith, General Services Department, be granted a regular pension tinder Section(s) 2.396
of the Employees' Pension Plan as recommended by the Pension Advisory Committee.
? and that the a ropriate officials be authorized to execute same.
BACKGROUND:
Norma F. Smith, Staff Assistant 11, Fleet Maintenance Division, General
Services Department, was employed by the City on October 4, 197€, and began participating i n
the Pension Plan on that date. Her retirement will be effective on May 4, 1995, at the beginning of
the day.
Ms. Smith's pension was approved by the Pension Advisory Committee at its meeting ' of April 5,
1995. Based on an average salary of approximately $26,791 over the past five years and tile
formula for computing regular pensions, this pension will approximate $15,739 annually. Charts
from f=inance which take into consideration mortality rates and age reflect the "present value cost
of financing" this pension will be approximately $195,267. The estimated pension cost (cash
payout over the life of the pensioner and his/her spouse) is $424,965.
Reviewed by:
Legal NA.
Budget NA.
Purchasing NA
Risk Mgmt. _ NA
CIS NA
ACM
Other _ NA
Submitted by:
City Manager
Originating Dept:
Fluman Resource,
User Dept.:
Advertised:
Date:
Paper:
E Not required
Affected parties
? Notified
0 Not required
Costs: $19,267 Commission Action:
Total
? Approved
- ? Approved w/conditions
Current FY ? Denied
? Continued to:
Funding Source:
? Capt. Imp.
? Operating
Er Other P@asion_ Attachments;
Appropriation Code: Letter(s)
046.07.410-614100-585- ? None
2
1
. . . '.it Otto tRifrljflS.y'
I T' Y. O F C L E A R W A T E R
POST OFFICE BOX 4748
CLEARWATER, FLORIDA 34818.4748
Human Arsourcea Depatement
8131482$87']
... .
TO: Honorable Mayor and Members of the City Commission as, 'T'rustees of the
Employees' Pension Plan
FROM: Pension Advisory Committee
COPIES: Debbie Bailey, Payroll Services Manager
Employee's File
SUBJECT:, Regular Pension-Norma F. Smith
DATE: April 5, 1995
The Pension Advisory Committed received an application for regular pension from
Norma F. Smith on March 30, 1995.
Ms. Smith . was employed by the city on' Octber 4, 1971, and has been a participant in t h e
Pension Plan since that date. The amount of Ms. Smith's pension will be computed by the
Finance Department at such time as her last fi ve years of service and salary can be
calculated.
motion
By made and duly carried at its meeting of April 5, 1995, the Pension Advisory
,
Committee approved/recommended a regular pension base d on years of service for
Norma F. Smith in accordance with Section 2,396 of the City Code. This pension will be
effective on May 4, 1995, at the beginning of the day.
I hereby certify that the Pension Advisory Committee has approved the granting of a
regular retirement pension for Norma F. Smith and the above dates are correct.
Chan, Hnsion Advisory Committee
/k, 'Equal Employment and Affirmative Action Employer''
d
PENSION REQUEST FORM
I Norma F. Smith do hereby 'apply for retirement from the City
of Clearwater
General Employees' Pension. Plan. ,
My. benefits date is October 4, 1972
(Entry date Into
pension- plan) .
M y date of hire is October g , 1971 ,
My birthday is January 220 1937
M job classification is StaffASSx,Ntaut 11 and 1. work in the
General services ..Department, Fleet Maintenance Division .
M y resignation date is may 3, 199s
The type of pension for which I am applying is (check only one):
x Regular Pension based on years of service
Job-connected Disability Pension
Non-job-connected Disability Pension
1+iy spouse's name is; Robert 11/8/35.
Dependent children under the age of. 13 and ,residing i n my ..household are:
(Print Childs Full `tame) (Child's Date of Birth)
I hereby certify all of the above to be true and cac;ecc -.---???
C rte. ZC*;
(Signature)
March 30, 1995
(Date) ^
STATE OF FLORIDA foregoing i t ument was 1Gk owl ged before me this
COUNTY OF PINELLAS ? C! by ?) r'? ?. it who is personally
lOwn -tome or who Ls produ&d -
''\1s idenri?-cation and w#t, not take an oath.
kl\ ~h^ 1 , `I9 Votary Public
(Signature)
Commission Yo..?
,y , ?,??` ?'?OSY? ?? { acneuWC'
3rf : t?[nte i
CO?A!'.lIrsSSUid i:L7. ?•__r?; "1
' e tnr
OPTION #I:' Employees : can receive a lump sum payment for vacation and
Holiday pay and 1/2 of accrued sick leave at the time of
separation from the City. There will be no 617b deduction for
pension from this lump sum payment nor will this amount count
as earnings in the calculation of the pension. The last day of
work will be the termination date and pension benefits will begin
the Followin; day.
OPTION #2: Employee can extend termination date by the time due for
vacation, holiday pay, . and 113 of accrued sick leave. Termination
date will be the final day of extended time. . Pension benefits will
begin the following day:
(Only available , to employees hired prior to 1011196.)
* * M * M * w Ye W ?t yV M M * +? 4t * M k M * w ye it # * M * * * s? It M m A ek ? k M bl W w ti M ve W N k M X W M * I[ hY k
I, Norma F. - Smith an employee of the City of Clearwater, hereby apply for
pension benefits under the City's Employees" Pension Plan.
I hereby certify. that I fully understand the twa options offered to me. I choose to retire' using
option T and wish my benefits to be calculated under this option.
I understand that once this form is signed, my decision is irrevocable.
EMPLOYEE'S SIGNATURE:
SOCIAL SECURITY : 338-34-5127
1104,Pineview Avenue-
%ViTLTESSES: ADDRESS:
! 1 Clearwater, FL 34616
r "'VVV `
N ZI\YJ? ti;umarch 30, 1995
TRUSTEES OF THE EMPLOYEES' PENS ON FUND Item #
Meeting Date: 5.1_119 5
Agenda Cover Memorandum
Subject:
Pension to be Granted.
Recommendation/Motion:
Robert E. Morrison, Parks & Recreation Department, be granted a regular pension under
Section(s) 2.396 of the Employees' Pension Plan as recommended by the Pension Advisory
Committee.
[] and that the appropriate officials be authorized to execute same.
BACKGROUND:
Robert E. Morrison, Lighting Supervisor, Parks & Recreation Department
was employed by the City on June 16, 1965; and began participating in the Pension Plan on that
date. His retirement will be effective on March 9, 1996, at the beginning of the day.
Mr. Morrison's pension was approved by the Pension Advisory Committee at its meeting of April 5,
1995. Based on an average salary of approximately $41,384 over the past five years and t h e
formula for computing regular pensions, this pension will approximate $31,038 annually. Charts
from Finance which. take into consideration mortality rates and age reflect the "present value cost
of, financing" this pension will be approximately $411,099. The estimated pension cost (cash
payout over the life of the pensioner and his/her spouse) is $1,039,775.
Reviewed by:
Legal _- NA
Budget NA
Purchasing . NA_
Risk Mgmt. NA_
CIS NA
ACM
Other NA
Originating Dept:
Human Resources
User Dept.:
Advertised:
Date:
Paper:
? Not required
Affected parties
? Notified
? Not required
opts: $411.099
Total
Funding Source:
? Capt. Imp.
? Operating
? Other Pan?j4n
Appropriation Code:
Submitted by:
City Manager
NQ
Commission' Action:
? Approved
? Approved w/conditions
? Denied
? Continued to:
Attachments:
Lettor(s)
? None
N.
6%-
C I T Y O F C'I. E A R W A T E R
POST OFFICE 80X 4748
CLEARWATER, FLORIDA 34818-4748
Human Resources Department
8131462.8870
Ta Honorable Mayor and Members of the. City Commission as Trustees of the
Employees' Pension Plan
FROM: Pension 'Advisory, Committee
COPIES: Debbie Bailey, Payroll Services Manager
Employee's File
SUBJECT': Regular Pension----Robert E. Morrison
DATE: April 5, 1995
The , Pension Advisory Committee received an application for regular pension from
Robert E. Morrison on March, 28, '1995.
Mr, Morrison was employed by the City on June 16, 1965, and has been a participant in t h e
Pension Plan since that date. The amount of Mr, Morrison's pension will be computed by
the Finance Department at such time as his last five years of service and salary can be
calculated.
By motion made and duly carried at its meeting of April 5, 1995, the Pension Advisory
Committee approved/recommended a regular pension based on years of service for
Robert E. Morrison in accordance with Section 2.396 of the City Code. This pension will be
effective on March 9, 1996, at the beginning of the day.
I, hereby certify that the Pension Advisory Committee has approved the granting of a
regular retirement pension for Robert E. Morrison and the above dates are correct.
Clt• rr n, Pension dvisory, Committee
''Equal Employment and Alfirmotive Action Employer''
PENSION REQUEST FORM
. Robert E. Morrison
I, do hereby apply for retirement from the City of Clearwater
General Employees' Pension Plan.
My June 16, 1965
benefits date is (Entry date into
pension, plan)
Zvi y date of hire is' June 16, 1965• ,
'lily birthday i5 May 1, 1982
My job classification is Lighting Supervisor and 1, work in the
'Park- & Recreation Department. Recreation Facilities Division.
My
March S, 1996
resignation date. is
The type of pension for which I am applying is (check only one):
x Regular Pension based on years of service
Job-connected Disability Pension
.von-job-connected Disability Pension
My spouse's name is: _ Pat ..---3/2 /46 ..,.._
Dependent children under the age of 13 and 'residing in my household are:
(Print Child's Full Name) (Child's Date of Bitch)
I hereby c:rtify all of the above to be true and correct:
(Si,narure)
" - March 28, 1995
-(Date)
STATE OF FLORIDA The fore oing i trument was acknowledged before me this
COUNTY OF PINELLAS 3 by 0390." L /3'Jo,' c ' who is personally
known m me or who has produced ' c X -°
as WZ?t h and who did/did riot take an oath.
?. ?"c•r:u.?,vr'4t:o`vL _?L/10 L t? it _Notary Public
sTATE O. ; LORIDA (Signature)
rM:.; r • Commission No._
IJV r?`fr', nEC. 6.1993 ,
1912(Name of Noraay Printed)
Cr ?? zo
' , 1 p'i.ij.:.yrs., _ •,ti' , ., .
CITY OF CLEARWATER
GENERAL 'EMPLOYEES' PENSION. PLAN
OPTIONS - GENERAL EMPLOYEES
OPTION #1: Employees can receive a lump sum payment for vacation and
holiday pay and 112 of accrued sick leave at 'the time of
separation from the City. There will be no 6% deduction for
pension from this lump sum payment 'nor will this amount count
'as earnings in the calculation of the pension. The last clay of
work will be the termination date and pension benefits will begin
the following day.
OPTION 42: Employee can extend termination date by the time due for j
,vacation, holiday pay, and 112 of accrued sick leave, Termination
'date will be the final day of extended time, Pension benefits will
be-in. the following day.
Only available to employees hired prior to 1011190.)
I, Robert E. Morrison an employee of the City of Clearwater, hereby apply for
pension benefits under the City's Employees' Pension Plan.
I hereby certify that I fully understand the two options offered to me. I choose to retire using
Option # 2 and wish my benefits to be calculated under this option.
I understand that • once this form is signed, my decision is irrevocable.
EMPLOYEE'S SIGNATURE:
i'SOCIAL SECURITY #: 034-40-3655
WI? ESSES:, ADDRESS: 2905 Rosery Road East
Largo, FL 34641-1255
C 0, t- r'_ LC t ;_ ,,,••? DATE: March 28, 1995
LL
r
- TRUSTEES OF THE EMPLOYEES' PENSION FUND
Agenda Cover Memorandum
Item # _(tt11_?
-
Meeting Date: 5 / J 19 5
Subject:
Pension to be Granted
I.I..I?YYW.??M*1 I I I I I II I 1/?..I..??IYPI.IIII.I..II.rY.W.1?lYYI?IiYYY?
Recommendation/Motion:
Michael J. Szuba, Fire Department, be granted a job-connected disability pension under Section(s)
2.397 and/or 2.399 of the Employees' Pension Plan as recommended by the Pension Advisory
Committee,
0 and that the appropriate officials be authorized to execute same.
BAC \GROUND. P.IIIILL.LL1.111..1 - --
Michael J. Szuba, Fire Lieutenant, Fire Department, was employed by the City on
March 7, 1975, and began participating in the Pension Plan on that date. On May 18, 1992, lie
suffered chest pains while on duty which is the basis for his request for this job-connected
disability pension.
Mr. Szuba has submitted letters from Dr. Robert Sanchez, dated February 22, 1995, and March 17,
1995; Dr. H. Andrew Hazlitt, dated February 8, 1995; and Dr. Hugh A. Rutledge, dated March 2, 1995.
The letter from Dr. Sanchez states, "Mr. Szuba experiences recurrent supraventricular
tachycardia which occurs without warning ...In view of this, I believe that he should no longer be
allowed to work as a fire fighter particularly in situations where the life of others, as well as h i s
own life, would be dependent upon his ability to perform ...the result in disability will very likely
remain a permanent and long-term problem." The letter from Dr. Hazlitt states, "Due to t h e
symptoms that Mr. Szuba experiences with this tachycardia, I. believe he should not be allowed to
work as a fire fighter...This is very likely to he a permanent problem." The letter from
Dr. Rutledge states, "Since the patient's job encompasses physical activity, usually under stressful
conditions, I do not feel that he should engage in this type of activity concerning his u n d e r l y i n g
cardiological diagnosis-Therefore, I recommend that he be considered disabled for his particular
job description." The Pension Advisory Committee approved Mr. SZUba's pension at its meeting of
April 5, 1995, based on the documentation submitted from the doctors and Chapter J12 of t h e
Florida Statutes which is the Firefighters' heart and lung bill (copy attached) which states that
any heart disease contracted by a Firefighter is presumed to be job-connected. This pension will
be effective on a date to be determined.
Reviewed by:
Legal NA-
Budget NA_ R?
Purchasing . NA
Risk Mgmt. _ __ NA__
CIS _ NA
A.CM?
Other NA
M.
Submitted by:
Originating Dept:
Human Resource;
User Dept.:
Advertised:
Date:
Paper:
L'SI Not required
Affected parties
? Notified
Costs: $490,533
Total
Current FY
Funding Source:
? Capt. Imp.
? Operating
ff Other Pension
Commission Action:
? Approved
? Approved w/conditions
? Denied
? Continued to:
Attachments:
Letter(s)
Appropriation Code:
Of Not required 646-07410-5142()0-58L
City Manager M
? None
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Agenda' Item-Michael J. Szuba
Page .2 i
t,'.. '. May 1995
Based-• on an "average ' salary of ap'proximately',' $38,139' over the , past five' years and - the
formula for computing.'.job-connected, disability pensions, Mr. Szuba's pension will
approximate $28'604 annually. ' Charts from Finance ' which take' into ' consideration
. ' ° 'mortality . rates and age.' reflect' the "present value cost of financing"- this pension: will be'
appraximateiy:: $4QQ,533. The estimated, pension cost (cash pAyout over the life of t h e
pensioner and, his/her, spouse) is-$l-i244,292.
rnk
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+> I T Y 4 F C L E A R W A T E R
11.
N -S
POST OFFICE 'BOX 4748
CLEARWATER, FLORIDA 34618-4748
Human Resources Department '
81314624$870
TQ Honorable Mayor and Members of the City Commission as Trustees of the
Employees' Pension Plan
FROM: Pension Advisory Committee
COPIES: Debbie Bailey, Payroll Services Manager; Risk Management
SUBJECT:' Pension for Michael Szuba-Job-Connected, Disability Pension
DATE: April 5, 1995
The Pension Advisory Committee (PAC) -received ah 'application for disability pension from
Michael Szuba on February 27, 1995.
Mr. Szuba has been determined by the Pension Advisory Committee to meet the
requirements of the Pension Plan for a job-connected disability pension. lie was employed
by the City on March 7, 1975, and began participating -in the Pension Plan on that date,
Further; he has submitted medical documentation, copies of which are attached, relative to
his disability which has been reviewed and approved by the PAC.
By motion made and duly carried at its meeting of April 5, 1995, the Pension Advisory
Committee approved/recommended. the granting of a job-connected disability pension to
Mr. Szuba in accordance with provisions of Section 2.397 of the City Code. This p ension is to
be effective on a date to be determined.
The amount of Mr. Szuba's pension will be calculated by the Finance Department according
to the formula in the Pension Plan for job-connnected disability pension 'at such time as his
last five years of service and salary can be computed.
1 hereby certify that the Pension Advisory Committee has approved the granting of a job-
connected disability pension for Michael Szuba and the above dates ar correct.
Chai? n, Pe s Qn Advisory Committee
L
` i .11 a ??1 IC? . •' L
"Equal Employment and Affirmative Action Employer"
I
iM
PENSION REQUEST FORM
I, Michael..J. Sz6a do hereby apply for retirement from the City of Clearwater
General Employees'. Pension Plan.
My benefits date is March 7, 1975 (Entry date into
pension plan)
M y date of hire is March 7," 1975
My birthday is March 11, 1955
My
Y job classification is ire Lieutenant
J _ _ ,.,.• _, _
and I work in the
Eire Department, Division.
M y resignation date is to be determined
The type of pension for which I am applying is (check only one):
Regular Pension based on years of service
x
____Job -connected Disability Pension.
' Non-job-connected Disability Pension
My spouse's name is: Kathleen 5/$/55
Dependent children under the age of '13 and residing in my household are:
(Print Child's I~uil Name)
(Child's Date of Birch)
I hereby certify all of the above to be true and correct:
{Signature)
February 27, 1995
(Date)
;ATE OF FLORIDA r--, The oreg?ig instrurr:c; t L:!?:?o?.vie??;ed before me this
COUNTY OF PINELLAS k?^ ice,, %Yho is -personally-
known to me or `%aho has produced\??
ficatian and who did/did not take an oath.
+ `\as id .ti
1}I?.. '?\
-;Notary Public
(Signature)
Commission No.
t. A ?' r'?L.??? C ??i`??, ?yi? `? ,? `t„ t?•?Nam.?...aE-Nox-ar inked)
OPTION #1: Employees can receive a lump sum payment ' for vacation and
holiday pay and .112 ' of accrued , sick leave at . the time of
separation from the City. There will be no 6% deduction for
pension from this lump sum payment nor will this amount c o u n t
as earnings in the calculation of the pension. The last day of
work will be the termination date and pension benefits will begin
the following day.
OPTION #2: Employee can extend termination date by the time due for
vacation, holiday pay., and 1/2 of accrued sick leave. Termination
date will be -the final day of extended time. Pension benefits will
begin the following day.
(Only available to employees hired prior to 1011188.)
*****«*************************«**********?
I, Michael J. Szuba an employee of the City of Clearwater, hereby apply for
pension benefits under the City's Employees" Pension Plan.
I hereby certify that I fully understand the two options offered to me. I choose to retire using
Option # and wish my benefits to be calculated under this option.
I understand that once this form is signed, my decision is irrevocable.
MNIPLOYEE'S SIGNATURE :.< SOCIAL SECURITY #: 262-29--9555
TNESSES: l ?,. ??• _ :ADDRESS: 1048 Kenwood Drive
Dunedin, FL 34696
'? ti ,? ?`. , 1 ?? ? ? ?? \``?;_,\1 Februar<? 27, 1995 •
DATE:
RE: fkhael l: S-.uba
lo whom it may t-onedi-n:
X am a 39 year'ala fire licutenant.with 18 ;•eam service, ,r`rlo in 1999 began to yuw tal :i
+:ardii c p?obl~~m.: The nrobizm bean oi:e 41V at file re station with a auddcn onset c•f chest'
pre.tiure rind palYlt3tions•R acute 3lt'atzrless =?!•ri1'ia. -.urt'??::tt1. IIJ% rC-wc rn:crs [tot+.ced :`lat E'•.':1:;
3shtn and diauhor4C1C. i ;cas '.•ril`ll:ilti d Io.r :1faIlte{.ii:;s M -hC rir .ytstiUn :lnl3 MUM, ,o t.iciton
Pant Hospital. € :vas kept over iu hE :E?r r:b5er-'atlen :[rid gi.•en 1 :j"Iallic, l :tress 11":x: atr4SS
• t ra e • e t 1 a ?
:.st ;r as n??3Li1'Z and T'v L1 as?d. Sanc hen i n;14°e been pVac; on vanous:nediQations..tiith .
little success in eliminatin- the irrhytl nias.' Th'e arrhvthmins ha'. e tncluded prermature atrial,
beatii. tachl.carclia aria periods rat ast go1e. € xntinued :o iuve rre:ble'ms. • e ,vas ranted 11v Dr.
1efferv Samar for 3 vears. `.Ve tried many combinatlons oI dn::Ys without suc-.aa.:fter t;vo v%! xs
of medication and still na improvetni?nt. i ccntacted Dr. anchez • she ;placeu me =an an ent
:n.riror ;tihich :,hog ed a ::inr:s :aclt!'cardia of unkrlo/rrn uriein. C)r.Sl.cln ::le : scr_t ltt'? to r. '
iazeiitt .vl:o is a sp-6alist ir. the electrical activity of the heat, fir. ":la?litt i;ldicated that he had
iG?w :fail: '.l e;v :uses !lke ::tine hich hate been ven, sy:t„ :rr_at :r•;=h : v!I ic:acion. ''til; ?ti,;
r: a ;err:,Lronl? antiarhythnlic: bllt ii has taco lean;! t:; d i:Elli ._? d:.:c; ;.:inutd. I-'..
:'fa,-i , :, f'•+yl .-!!ei `Riia
it toles illy s.t ;'e?iti?' 'iL1?:t:l.::.S L'ltf, ,l• :1 il:''.V
. fll?i:]Ilie hr•..i~..1.:, :ti
?'' ?r.'a•• ^: ;:erg
I1. ::i iS a ?.rua,;:EE'.LCC ;?'h eCC ;l ?'[ iie i {]t ti1L}14`I::CS Ei'. ^.l'3l'•:Q iii i 1'"I
l:u?f• :T. Ifl'. .:a lrw;? rj 1 [• r
.:..c FLl` ne::rt c':)r sl
' '!• + t.m y! ri• ri It :t?,t:.::,.s i:r .,:?
fit. 1^???' C L elrtilti1?, r. i_
ar.a tiaus n? ;he U F•w ! _ :r- ,r . , ?:::^
.r i• m. weed t' ;i l : ne ....:s, u
"4i. fir` ' t ` rr. 1. .p •? «?:
flit' -:[n:; and r?5t.rilin?? normal :?1Ie. SL':::.-,Sti.
.111:1.hat • il:''J;?1 Vr:: a in h;.-- -i-m1..5-1:El d'•:.?t .n4 I:y:frl. i?11R !.. ?1:'.T'11I.'r:ir".::.. L•• •3•. ,1..'w.. •r•li,l?l:
14 4e'1?t+r..'=tf..3. e:a!`I.Cr)i. J .iE'rl :L1' '. ewSIin.`i. •1'hl' :>1:'fiJ:;-s}4: u:. ::i .'t:.l'.'=.Il: ?_` • :liH%=: ;h]ilz ;L:.:il .lS .il.,,...,.
pnvii-aI -zertfon.
.•Y i?. •a 1,r?r 1M 1 ?• S f. i .,?
..i+ 'r. 5-c,nyr.,:.anL _..= Mi1tt..:?. I :I:.ti : u1?•.l:.. ,-:: Luz-?l..w:c:i=..?:li`... .....
.fin no ILn'er "rform file ?tltI ;af :l nr; uahten aoth ?:s•:•s I.•c-en ;,rnwid,-d .t loo?
'.lets+.iticnal inf, -natit;n fht _ ;ati=?r ll ?•: =r.-.,.:;..:; . ..: ...
!i" •.^•Y.:aC rei: -M 1-•eedi al ?rcliiremerta
- ...i... . r
S. '
r 'L.: t11'? n :1?. •''tLIll IC1'
i tl
IC;. :EC' 1L -ve I`eC' I'1.... .,:i' .:fi'r. - ..'....
F 70
:iinereit
zuba
??" ?A.' eF w?S.'I? *?r •• •??''?? ,... .. .li .r ... ?. I .'ii ? ? •. 1 • I .F. - .. r - {.
y.r.?.......- »«•w?.-«w ..?.?.-....... w.rr.. ._.. .......,,.,.•. .-......r• .«-e ... ..r .mow ..«........ ?........ • • .... .w•...,.._. .... «.. ?..-..+..?_.•-+.rrr i '
N.-.nom-. w.........r J..... _...._r .._ ...?. .._.. .. ._ .... ... .. .... .. _.. . .... ... .... ..- -? ....... •
Suncaa'st Cardiology Associates . .
David D. Dieterich, D.O., FA.C.C. * Robert Sanchez, 111.D., FA.C.C. + David E. Jacob, 1+1.D., FA.CIC:
March 17, 1995
Re: Szuba, Mike
To whom it may concern:
Since ''my letter dated February 22, 1995, there has been some question regarding the
permanency of Mr, Szuba's cardiac dysrhythmia, and his subsequent disability, The cardiac
dysrhythmia that Mr.' Szdba is suffering fromwill be a long-term problem, requiring some form
of therapy. Given the variability and the natural history of these dysrhythmias, there is some
uncertainty of whether the dysrhythmia will be a permanent problem. It is my opinion, however,
that at this time given what is known about Mr. Szuba's condition that the cardiac dysrhythmia
and, the result in disability will very likely remain a permanent and long-term problem.
Thanking you in. advance for your assistance in this regard. If .you have any questions, or if
can be of any further assistance, please do not hesitate to contact me.
Sincerely,
Robert Sanchez, M.D., F.A.C.C.
RS:vj
DT: 03/20/95
Dictated
But Not Bead
7540 66 Street North a Suite :;02 - Pinellas Park, Florida 31665
23.19 Sunset Point Rd. , Suite 403 ? Clearwater, Florida 31625
(513) 545-3364 (24 hrs.) FAX (813) 544-7389
t :? -
?ti-?•,.r......r..?...-r.-..-.ww....+...?.......w..>. ?.. w._ ...w-...w^=+^....w.-?..--+.. .? ...-...-«. r .-..???...? ..? • ...r?.w....r..-.....?
f
Sancoast Cardioiog Associates
David D. Dieterich, D.O., FA.C.C. • Robert Sanchez, 11.D„ F.A.C.C. * David E. Jacob, &I,D.,, FA.C.C.
February 22, 1995
Re: Szuba, Mike J.
To whom this may concem:
Mr. Michael Szuba is a 39-year-old gentleman who-has been under my care since October 21,
1994 for the evaluation of recurrent supraventricular tachydysrhythmias. Mr. Szuba
experiences recurrent supraventricular tachycardia which occurs without warning. With the
tachycardia the patient does become quite symptomatic experiencing symptoms of palpitations
as well as chest discomfort and shortness of breath. These episodes occur more frequently
under periods of stress: When he does experience his above noted symptoms, his
performance does become impaired.
In view of this, I believe that he should no longer be allowed to work as a fire fighter particularly
in situations where the life of others, as well as his own life, would be dependent upon his
ability to perform. The cardiac dysrhythmia that he is suffering from will be a long-term
problem; however, It is uncertain at this time whether it will be a permanent problem. He has
been seen by Dr. H. Andrew Hazlitt for electrophysiologic evaluation. Mr. Szuba did undergo
electrophysiologic study in an attempt to perform radiofrequency catheter ablation in an effort
to cure this disorder, Unfortunately, the dysrhythmia was not able to be induced and therefore,
not able to be ablated. At this point there does not appear to be a curative solution to his
problem and he will require long-term, drug therapy. Unfortunately, the drug therapy has with
it side effects which may also impair Mr. Szuba's performance. In view of the above It is my
opinion that he should be completely disabled from performing his duties as a fire fighter.
Thank you in advance for your assistance in this regard. If you have any questions, or if I can
be of any further assistance, please do not hesitate to contact me.
Sincerely,
Robed Sanchez, M.D., F,A.C.C.
RS:vj
DT: 02/22/95
7800 66 Street North v Suite 302 a Pinellas Park, Florida 34F65
2349 Sunset Point Rd, , Suite 403 o Clearwater. Florida :34625
(813) 545-3864 (2-4 hrs.) FAX (813) 544-7389
r ,
\/lei. YL VHi.1LGL L/Ul Ui?JVYyIJ YIYl VL/iJUilYiil.J
1100 Clearwater. Largo Road 30527 U.S. Hwy. 19 North
Largo, Florida 34640.4131 Suite 300
"(813) 586.0021 Palm Harbor. Florida 34684
FAX 1813) 581.0386 (813) 784.0021
Donald R. Eubanks. M,D.
Michael'D. Williamson. M.D,
Paul L. Phillips, M,D,
Jose 1„ Gallastegul. M.D.
Douglas J. Spriggs, M.D.
Vanessa J. Lucarelli. M.D.
Bernardo Stein, M.D.
Jorge P. Navas, M.D.
H. Andrew Haditt, M,D,
February 8''1995
11. '
To Whom It May Concern:
RE: Michael Szuba
I have been treating Mr. Michael Szuba since November 30, 199.4. He
was sent to me by Dr. Robert Sanchez for'evaluation for supra-
ventricular tachycardia. Please see , my enclosed . initial
consultation and subsequent office notes for the full details of
Mr. Szuba's history..
Basically, Mr. Szuba is suffering from a form of episodic rapid
heart beating. This can occur without warning at any moment and
produces symptoms in.Mr. Szuba of an awareness of a rapid pulse, a
feeling of palpitations in his chest and some associated chest
discomfort and shortness of breath. Due to the symptoms that Mr.
Szuba experiences with this tachycardia, I believe he should not be
allowed to work as a fire fighter, particularly in situations in
.which.his life or the lives of others might be dependent upon his
ability to perform at maximum physical performance. Therefore, it
is my.opinion that he is disabled from performing his duties as a
fire fighter. This is very likely to be a permanent problem.
Unfortunately, there is no curative solution to this problem and,
therefore, it will require long-term drug therapy in an attempt co
reduce the symptoms of this disorder. Heretofore, we have had some
improvement in Mr. Szuba' s symptoms ; • however, we have not been able
to render him symptom-free.
Please contact me should you have any further questions.
a
i
fS'incerely,,, P
t H. Andrew HazliEt,;,
HAH : pint / cw
Enclosures
r
t t
s
DRS. POLIN, RUTLEDGE AND FISCHER
Palm Harbor Medical Center
34637.U.S.. Highway 19, North
Palm Harbor', FL 34684
Telephone: (813) '786-1673
3/2/95 CONSULTATION/
S3UBA,.MICHAEL' PROGRESS NOTE
This is a'39 year old, married, white male'who hasn't smoked in 9 years. He
presents for evaluation of 'cardiovascular disability. , This patient
apparently has had, since.1992, symptomatic palpitations. He has undergone
extensive work-up' at Suncoast Cardiovascular' Associates, including an
electrophysiological study at Clearwater Cardiovascular Consultants by Dr.
Hazlitt. Apparently, his symptoms are rather severe, precipitated by no
particular stimuli; occurring occasionally at rest and occasionally during
exertion. The patient denies any caffeine provocation.
His work-up to date has consisted of a Holter Monitor documentation of atrial
and sinus tachycardias up to 130 beats per minute. He has undergone an Event
Monitor. He has also undergone a Thallium which showed no ischemia and the.
electrophysiologi.cal studies. Apparently, there was an attempt at ablation
therapy, but because of the proximity to the SA node, this was not
undertaken. In the meantime, he has been controlled fairly successfully with
the combination of Calan SR 180 and Corgard 80 mg.
The patient has no history of rheumatic heart disease,. He carries no history
of mitral valve prolapse, although one of the previous records that we
reviewed showed that the anterior mitral valve leaflet is suspicious for, Lut
not diagnostic of prolapse.
RISK FACTORS: He carries no history of hypertension. No history of
premature heart disease.
f '
t '
Page Two
Michael Szuba
REVIEW OF SYSTEMS
GENERAL: No weight change; recurrent fevers, or significant fatigue.'.
HEENT: No complaints of hearing loss, ringing in the ears, ear infection,
nosebleeds, sore threat, hoarseness or swelling of the glands.
CVR: As above.
GI: No complaint of abdominal pain, nausea, vomiting, melena, hematochezia,
hemorrhoids, jaundice, diarrhea or constipation.
CNS: No complaint of trouble speaking, frequent headaches, vertigo, loss of
consciousness, arm or leg weakness, or paresthesias.
MS: No complaint of leg pains, joint pains or muscle pains. No joint
swelling.
GU: No complaint of dysuria, urinary frequency, urinary hesitancy, nocturia
or discharge.
SKIN: No new lesions.
BREASTS: No lumps appreciated.
GENITALIA: No discharge or bleeding.
PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure is 100/64. He is afebrile. Pulse is 58 and
consistent with a sinus arrhythmia.
HEAD: The pupils are round and equally reactive. The extraocular muscles
are intact. 'rhere is no conjunctival icterus. The oropharyn{ is benign.
Tympanic membranes and auditory canals appear normal.
NECK: The neck is supple and withoutjugular venous distension, nodes or
thyromegaly.
LUNGS: The lungs are clear. No wheezes, rates or rhonchi. Where is'no
dullness to percussion. Breath sounds are equal bilaterally.
HEART: The heart is in a regular rhythm without rubs, murmurs or gallops.
No extra systoles.
VASCULAR: The carotid upstrokes are full and there are no bruits. The
femoral pulses are also full and without bruits. Dorsalis pedis and
posterior pedal pulses are full and symmetrical.
ABDOMEN: Soft and non-tender. No masses or organomegaly. Bowel sounds
present and normal.
RECTAL: The stool is brown and heme negative. The prostate is normal in
size and consistency and is non-nodular.
Page Three
Michael 5zuba
GENITALIA: The testicles. are 'normal insize and symmetrical --nomasses.. No
penile lesions..
BREASTS: No masses or retractions.
LYMPH NODES: No cervical, azillary, epitrochlear or inguinal
lymphadenopathy..
SKIN: No significant lesions.
EXTREMITIES: No'?cyanosis, clubbing or edema. No joint deformity.
NEUROLOGIC: Alert and oriented times three. The cranial nerves are intact
and are symmetrical. The deep tendon reflexes are equal and normoreactive.
Motor and sensory function are equal bilaterally. No pathologic reflexes.
I
DISCUSSION: Review of copious data reveals the diagnosis of symptomatic
atrial arrhythmias, along with the diagnostic studies mentioned in the
present illness.
IMPRESSION:
1. SYMPTOMATIC SINUS ARRHYTHMIA WITH TACHYARRHYTHMIAS UNDER FAIR CONTROL.
PLAN: Since the patient's job encompasses physical activity, usually under
stressful conditions, I do not feel that he should engage in this type of
activity concerning his underlying cardiological diagnosis. He certainly can
present a risk .to himself and perhaps even others if he were to have a
tachyarrhythmic episode while performing 'activities. Therefore, I recommend
that he, be considered disabled for his particular job-description.
HAR/ 1 j t Hugh. -Rutledge, M. D.
•1f li1e% ?'.> i.?4?? ••.?P'i!t fie%? ?_ -.sw•1Qt L'a1?.N! i.L'rL' .+« .,1.1 ?r•N t•.t A,.1, 0_21L_. r r
1
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Ch. 112 PUBLIC OFFICERS AND EMPLOYEES; GENERAL PROVISIONS
disability or death shall be resumed to have been accf•
P whose res onsibility i
primary p is th
r? dental and to have been suffered in the line of duty and disposal of explosive devk
•
?; s unless the contrary be shown by competent evidence, includes any full-lime ollicer or eml
However, an such fireman shalt have successful) an political subdivision of the SIDI
passed a physical examination upon entering Into any to chapter 943, whose duties rec
such service as a fireman, which examination failed to serve recess or to attend terms
reveal any evidence of any such condition. Such pre; tourt as bailiff,
'
?? tr sumption shall not apply to benefits payable under or (c) 'Insurance
means insuran
, ze
' granted in a policy of life insurance or disability fnsur stock company or mutual compar
:t?•
t ff ance, unless the Insurer and insured have negotiated for exchange authorized to do busines
such additional benefits to be Included in the policy can.
t
t state.
'
'
rac
. (d)
Fresh pursuit
means the
2 This section shall be construed to authorize the
()
who has committed or is reasonat:
3. I above governmental entities to negotiate policy con- ing committed a felony, misdemea
?P ,,
f tracts for life and disability insurance to include acciden. or violation of a county or municipa.
!f;t? ri lal death benelits or double indemnity coverage which does not imply instant pursuit, but f
shall include the presumption that any condition or sonable delay,
impairment of health of any fireman caused by lubercu (2)(a) The sum of 325.000 shal'
rd?ti losis, heart disease, or hypertension resulting ill total or in Ibis section when a law enforce'
partial disability or death was accidental and suffered in correctional probation officer, whir,
the line of duty. unless the contrary be shown by compe• formance Of his taw enforcement ,
tent evidence. killed or receives accidental bodil
. rauory..-t 1, Ch 65•00. , 1. C„ 73.125;, M. 0 rr.rrR in the loss of his fife within 1 year, i;
112.182 "Firefighter rule" abolished.- ino is not the result of suicide and
i (1) R firefighter or properly identified law enierce• is not intentionally self-inflicted.
(bl The sum of $25.{100 small t:
I„
'??
% ment officer who lawtuily enters upon the premises of
i
th
t
t
th
h
f hi
t
t
di
i
d
this section it a law enforcement, c
Y .`
t
it
,
l arge o
s
y occup
e s
a
us
ano
her
es
n
e
sc
u
tional probation officer is accident
,
„
44 of an invilee. The common law rule that such a firefighter
in paragraph (a) and the acciden
or law enforcement officer occupies the status of a result of the officer's response to
licensee is hereby abolished,
(2) It is not the intent of this section to increase or
ollrcer's response to what is leas
diminish the duly of care owed by prcgerty owners to an emergency. This sure is in ad,
vided !or in paragraph (a},
invitees. Property owners shall be liabte to invitees put, (c) It a law enforcement. Gone
k , scant to this section only when the prooerty owner negli• pi,4balion ollicer, while engaged
gently tails to maintain the premises in a reasonably sale is un
his law enforcement duties
. • condition or negligently falls to correct a dangerous con- ,
ally killed or dies wilhin I year as .
dilion of which the, properly owner either knew or should
i
h
f
l
l
k
lul and rnlerrlianal act, the sum o
gent
y
e care or negl
ave
nown by the use o
reasonab as provided in this section.
fails to warn the irtvilae of a dangerous condition aboul (d) Such payments. pur5uan
r
I
'. which the properly owner had, or should have had, paragraphs (a), (b), and (c), whe
VA
,.? l knowledge greater Than that of thr, invilee.
,,,,,o,r,_. , ?„ m•3oq ance or not, shall be made to the!
by such faw enforcement, corre,
± 112.19 Law enforcement, correctional, and correc• probation officer in wriling, signe,
e ors I ki tional probation officers; death benefits.-- to his employer during his Ir1e11rnr:
r ;? ,;t ?
•;'.,: h, :; I (t) Whenever used in this section, the lerm7 is made. then it shalf be paid to t'rr
'
;
;;. '?c ll?; (a) 'Employer means a state board. cemm ssron, dren and spouse in equat portion
,1
,+ •' L department; division, bureau, or agency, or a county, vrnng child or spouse, then to h
' •"
' #-
;?;
IT
I
municipality, or other political subdivision of the stale,
a benelicrary is not designated a,
_
cS+y •? ' +-? which employs, appoints, or otherwise engages the ser• cnild, spouse, or parent, then
T vices of law enforcement, correctional, or correctional estate.
Isrrlbation officers. (e) Such payments, pursuaf
?? ;y} s I
'
Z (b) "Law enforcement, correctional, or correctional
' paragraphs (a), (b), and (c), arri
i
,
'
as:
, - w , probation office(
means any officer as defined in s. )
compensation or pension
ers
.+r''' "s wi. ti . s
ern
943, 10{ 141 or P!oyes of Nye state or arty political sub"
from the claims and demands r•
( division of the state, including any law enforcement offi" enforcement, correCtional, of ro
cer, correctional ollicer, correctional probation officer,
r
li
n
r
v
•
ti
bli
t
t
tt
t
d
f
i
d cer
l) 11 a full-time law enforc
I. ga
or
ga
a
nves
or. o
pu
en
e
in
es
s
e a
ey
c
e
for
whose duties require such officer or em
lo
ee to (
1orrectional probation ollicer v+r?•
e ti
F ,
p
y
w,?
.
+
f' '?'. ? ," •?.
; ti
investigate, pursue, apprehend, arrest, transport, or
ed with
ersons rrho are char
maintain custod
of
sus;
3oency is kiftad in the ine of r1t.
ol•nclence inflicted by another
g
,
p
y
# petted of committing, pr convicted of a crime; and the 1s eno-tge[1 in Ihn perlarman'
l'
? ' , farm includes anv rnernher of a bomb dv rosal find lulles or as a result of an ass
PUBLIC OFFICERS AND EMPLOYEES: GENERAL PROVISIONS Ch. 112
'Ile Cotinly and to onlnr into r'nnlractn wflli (2) I! is this mlent anti purp4sr: pl thi:, sechnn love^,t
,panics to provide suril tnsurance. in ilia public ulhcers, agencies and commis.,;,r-ns herein
•9-;t,r enurnernfed the sole power and discretrnn to ,rnprove or !
acal governmental group insuranrr. disapprove requested deductions and the •3pprovil of
.
s with respect to overcharges by provid• and making of anoroved deductions shall nol requira the
ipanl in a group insurance plan offered by approval or making of other requested deduclions,
lrr.tery,_.s t ch 54• It'?). i 75, cn "J. tnr)
'cipalily, school board, local governmenlal
,,If taxing unit, who discovers that he was 112.175 Employee wages; withholding to repay
oy a hospital, physician, clinical lab, and educational loan,--
;re providers, shall receive a refund of 50 (1)(a) Any person who has received an educational =
7 amount recovered as a result of such loan made or guaranteed by the stale or any of its polrti•
o to a maximum of $1,000 per admission, cal subdivisions and who at any lime becomes or is an ;
ces of overcharge shall be reported to the employee of the stale or any of its political subdivisions ! I
Cost Containment Board for action it shall be deemed ,o have agreed as a condition of his
•nate. employment to have consented to voluntary or involun•
,4].' 92, ? 1. Ch 91.48
1-4 83, ;n 7I•J]..od,tinetl ilia ..ronn Core Gost Canon
tary withholding of his vraQes IO repay such loan. Any
,tare ae M+r't. uurKS .'+d f mc+'rr,% t.rpps, perncr ,?t, such employee who has defaulted or does default on the ,
•,tr7 [' t cf +co'cprnt-ena I"Cd'Ignl, fr 4!'+.r fpnhi pl
4,5, p4eali Nro?rn C.,e
?: r +?emr„oi,.,..n
repayment of such loan shall, veilhin 60 days after ser•
I
vice of a notice of default by the agency holding the loan
singe In position or reclassification; con- to the empfoyee and the employing agency, establish a ; s
,sumption of membership in retirement loan repaya,enl schedule -:+hich shall be agreed to by
both the aqcncy holding the loan and the employee for Ii
'son who is a participant to any slate or repaying such defaulted loan through payroll deduc•
-3nl system, who changes his possliCon of lions, Under no circumstances rrlav an amount in excess
.r who is reclassrlsed so that under any sf 10 percent cer pay period o! the pay of such
c!1 person world participate in a drflerent !molovef, be required by the agency holding the loan as 1 ;
tern, may cr.ntinue to participate and pail of a repayment schedule or plan. If such employee ,
,e same rettremenl system in v.-htch tie fads to establish a repayment schedule within the speci•
came under before changing positions or lied period of time or fails to meet the terms and condi•
1
ad so tong as such person remains in the lions of the agreed to or approved repayment schedule
tale or county and conlsnues to make the as authorized by this subsection, such employee shall
enuired 1W 1-i%y. Any person who has be deemed to have breached an essential condition of
ons or been reclassified heretofore may employment and shall be deemed to have consented to I I ri
:er and parlrc'pal? in the retirement sys- the involuntary Ihholdmq of his -.vages or salary for the T k l r?i
belonged belere such change or reclas• repayment of the loan.
payment of ail back contributions, plus (b) No person .,ho is employed by the state or any ;! I ;)
?st per annum, that he wculd have been of its poirtical subdivisions on or after October 1, 1986,
v had he continued to participate and may be dismissed for having defaulted on the repay.
1 system conlrnucusly, such election to merit of an educational loan made or guaranteed by the
yvment to be made on cr before the time stale or any of its political sut:divisions.
(2) The Administration Commission shall adopt rules
-tsions of Ihis section shall supersede to implement this section, :,hich shall include, bul not i
relating to stale and county :etiremenl
be limited to, a standard metnod of ca;r ilalinq amounts I
r;
;ions, provided ncthinq herein shall he to be withheld front r;rnployees.-.no rave failed to eslao• ;r
ply to Stale Supreme Court justices, as li5h a rtmayment SCtI+?dole vnthin the :,pecified period of
it.er 25: nor to circuit fudges as provided lane or failed to meet the terms and conditions nt the
' l
or to members of Duval Ccunly'?mplov- agreed to or approved repaymenl schedule ,,^•trzvtoed frr = j
t
'd as provided to chapter 23259. Icts, in this seclion. Such rnnlhcri ":hall ronsrder Inn 'ollowinq
led by chacler 27520, Acls, 1951, and factors: O
•?Cts, ir5l. (a) The nniounl of the loan ditch fRrllalnS oUlsland•
' ir1U' ? rt
ctoyee wage deductions.-- (h) The incrrnf', of flip arnnlnvef, ::ho ot•re, such
Thos. munrC oalttitrs• and special dis- amount; and
(c) Other factors such as this n?.=rrt7r?r r1 rtr_7endf?nt ; I
t
'
ate and the deparlme'+ts• agenrleS, supported by the employee I
iI
3stens, and officers thereof ara aultior• t,,,ey _z. t -" 8 •';9
'led ;n their sofe discretion to make
the salary or v:'aoe of any employee or 112.18 Firemen; special provisions relative to dis• J
.ch ?mount as shall be authorized and ability.--• '
:h employee or employees and for such (1) any corldtlion or impairment of health of any Flor• I
be authorized and requested by such id,1 municipal, cotinly, port authority, special fax Oslrrcl,
Ofcyees and shall pay such sums So or fire rontiof district fireman ;aused by tuberculosis, l;
=tied by such employee or emrlcyr!?5 held diseise. or nvpertension rpsullrng to lolal or partial I t
775
I
f
DIVISION MlcmFILM
FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
f11S% rAAtJnC-7M2'RT DIVISION OF WORKERS' COMPENSATION
Gilt' of CI"q ",'! 1'800'342.1741 (or) contact your local office for assistance
P. 0. But 4746 NOTICE OF INJURY
Report all deaths within 24 hours (904) 488.3044,
Clearwater, FL 34618 MAY 2 u 1991
a>uol n?cr wcnnuATlnu
FOR CARRIER'S DATE STAMP
RECD 13Y CARRIER SENT TO DIVISION
NAME {Fuel, Middle, Lost) Social Security Number Delo and Time of Accident
Michael J. Szuba. 262-29-9555 5/18/92 1001 hrs.
H D R S (Include Zip) EMPLOYEE'S q RIPTI N OF ACCIDENT
610,Franklin 5t:, CLwtr., FL 3L4616, ,...sudden onset of chest pressure ...rn4tine actin
TELEPHONE u., 462-6300 DES FII13E"NJUVY 4 DISEXS EAND INDICATE PART O BGDY AFFECTED
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7704 F i ref i hter Cis
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UATe F BIRTH SEX DID YOU REQUEST MEDICAL CARE? CXYES ? NO
3/11/55 1 CxM C1 F IF YES, Olt) EMPLOYER PROVIDE MEDICAL? EXYES ? NO
EMPLOYER iNFORMATICIN
FIRM'S NAME AND ADDRESS FEDERAL I.D. NUMBER DATE AND TIME FIRST REPORTED
City of Clearwater, Dept. 1220 56-60000469, 5/18192 1001 hrs.
P.O. Box 4748 W,C, COVERAGE BY POLICYIMEMBER NUMBER
Cleamater, FL 34618 0INSUHANCEC0. ELF-INSURED
NAME, ADDRESS, TELEPHONE OF
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TELEPHONE
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462
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PLACE OF ACCIDENT (Street, City, County, Slate) Post Office Box 3318 LAST DAY PAID THROUGH
520 Sky Harbor Drive Sarasota
FL 34230 +
,
Cleamilater, FL (Pinellas) I-800.749-304'4 RATE
O
F
PAYY ?HR 0WK
NAME, ADDRESS AND TELEPHONE
OF PHYSICIAN OR HOSPITAL ?
7
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s-!•1 f , P 4fl ? PAY ? m0
umber of hours biweCR !
?
Olp THE EMPLOYEE KNOWINGLY REFUSE TO USE A SAFETY Morton Plant Hospital Numbcaof hours '
APPLIANCE PROVIDED BY YOU, THE EMPLOYER? OYES ONO 323 Jeffords per week
DAT
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AST DATE EMPLOY
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FL p
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2/14177 r 5(18/92 r , PAID FOR DATE OFUIJURY
RETURNED TO WORK ? YES C? NO AUTHORIZED BY EMPLOYER YES ? NO YES IN NO ?
IF YES, GIVE DATE ._. L _ LOCATION ADDRESS
WAS INJURY FATAL? ? YES E4 NO
IF YES, GIVE DATE OF DEATH? rr (LOCATION x If APPLICABLE)
AGREE 1NITH DESCRIPTION OF ACCIDENT? NATURE OF BUSINESS
EE
O.41
? NO IF NO ATTACH EXPLANATION
Arty erson who, knowingly and with Intent to injure, defraud or deceive any employer or employee. Insurance company or self-insured program, files any statement of
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07oyee t
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? to Person C y-MAir >
flat available for signature ,,?
- --,• -
EMPLOYEE SIGNATURE III m labre to sgnt DALE EMPLOYER SIGNATURE DATE
CARRIER INFORMATION
Carrier Audit 0 Location 0 Service Co. k Carrier File ik
? 1, Controverting Case-DWC•12, NOTICE OF DENIAL'ATTACHED
? 2. Lost Time Case-Data of First Payment_ I ? AWW Comp Rate First day of disability
-Date of First Contact with Claimant r ? In Person ? Telephone ? Mail
-Notice Fled Dua to Multiple Pariods of Disability. Dates Covered by First Payment
C] T.TD, ? T.P.D. Date Form Rac'd, ! ? Catastrophic ? P.T.D. ? Death
? 3, Medical Only which became a Lost Time Case, (Complete all information in item 2 above)
REMARKS: ---
ADJUSTER NAME. CARRIER NAME, ADDRESS d TELEPHONE,
DATE; ! r
ADJUSTER SIGNATURE;
[ties. W
L>"S form QV+C?111r91)
EMPLOYPR COPY