Human Resources (HR)


Standard Operating Procedures


Retirement Long-Term Disability

Original Effective Date:


Revised Effective Date:






  1. Guidelines, instructions and forms are available on pages 161 - 181 in the Retirement Employer Manual.




  1. Complete a Form DIP-4, “Application for Long-Term or Extended Short-Term Disability Benefits” approximately 90 days prior to the conclusion of the short-term disability period.  Form D-4 is available on pages 180 - 181in the   Retirement Employer Manual.


  1. This form should be completed by the employee or legal representative, signed, and notarized.


  1. HR should complete the employer certification section of the form.


  1. The following forms must be furnished with the Form DIP-4 or as soon as possible thereafter:

·   Form DIP-1, “Application for Short-Term Disability Benefits”

·   Form DIP-E1, “Employer Master Worksheet for Determining Eligibility for Short-Term Benefits”

·   Form 7A, “Medical Report”

·   Job Description

·   Ret-170, “Authorization Agreement for Direct Deposit”

·   Ret-HM, “State Comprehensive Major Medical Plan “Retired Group Enrollment/Change Application” (NOTE: This form should be filed only if the employee has at least five years of retirement membership service earned as a teacher or State employee.)


  1. Maintain copies for file and send originals with a cover letter to the Department of State Treasurer, Retirement Systems Division, 325 North Salisbury Street, Raleigh, North Carolina  27603-1385.


  1. If the employee has been approved for disability or retirement Social Security benefits, a copy of the Social Security Awards Notice indicating the amount and the effective date of such benefits must be provided to the Retirement Systems Division as soon as possible.


  1. If the employee notifies Human Resources that he/she has a claim pending for Social Security benefits, the upper portion of the Form D-4 should be completed and submitted to the Retirement Systems Division.  Form D-4 is available on pages 180 - 181of the Retirement Employer Manual.