New Jersey police officers and firefighters applying for ordinary or accidental disability retirement through PFRSNJ need this two-page report from a personal or treating physician. It records treatment history, the last physical exam, physical findings and diagnosis, diagnostic data, and whether the member is totally and permanently disabled from assigned duties, including whether that results directly from an accident during regular duties.
The member completes Part One before presenting the form to the physician. The personal or treating physician completes Part Two, items 6 through 14, and signs with degree, specialty and New Jersey license number.
Download the current version from the source each time; forms change without notice.
Medical Examination by Personal or Treating Physician (PFRSNJ Disability Retirements)
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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BD-1177 is the treating physician form for Police and Firemen's Retirement System of New Jersey disability retirements and goes to PFRSNJ. BD-0021 is the Division of Pensions and Benefits version for other systems such as PERS and TPAF. The questions are nearly identical.
No. The form asks the physician to complete it in its entirety. Office notes may be included for more documentation, but every question must be answered on the form itself, and an incomplete form is returned to the member.