- Guidelines, instructions
and forms are available on pages 161 - 181 in the Retirement Employer
- 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.
- This form should
be completed by the employee or legal representative, signed, and
- HR should complete
the employer certification section of the form.
- The following
forms must be furnished with the Form DIP-4 or as soon as possible
Form DIP-1, “Application for Short-Term Disability
Form DIP-E1, “Employer Master Worksheet for Determining
Eligibility for Short-Term Benefits”
Form 7A, “Medical Report”
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.)
- 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.
- 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.
- 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.