General Information & Application Process

Short-Term Disability

• Must have at least one year of contributing membership service in the Retirement System earned within 36 calendar months preceding the disability.

• Must be found disabled for the further performance of their usual occupation.

• Must have been continuous and incurred at the time of active employment.

Employees may wish to apply for Short-Term Disability benefits under the Disability Income Plan of NC if they are disabled to the extent that they can not perform their regular job duties.

Short-Term Disability benefits are payable ONLY after meeting a 60-day waiting period (i.e. benefits would not begin until the 61st day) and would last for 365 calendar days if the employee meets the following requirements:

60-Day Waiting Period

• During the 60 day waiting period the employee MUST exhaust Sick Leave. This includes all Voluntary Shared Leave Donations.

• Once their sick leave has been exhausted they may choose to exhaust Vacation and/or Bonus Vacation or they may choose to go on Leave without Pay (LWOP).

• Once all leave is exhausted they MUST be placed on LWOP.

Note: The employee may continue to exhaust leave during the benefit period (after the 61st day).

General Information• Monthly Short-Term Disability benefit equals 50% of

1/12th of your annual base rate of compensation plus 50% of 1/12th of your annual longevity payment (if applicable).

• Short-Term Disability payments begin either on the 61st day, or the day following the LWOP date, which ever is later.

• Disability checks are mailed the day before payday directly to employee’s home.

• Person in receipt of disability benefits while on approved leave without pay may continue their State Health Insurance at the same rate charge while actively employed provided the person has at least (5) years of contributing membership from the Retirement System.

General Information• While in receipt of benefits from the Disability

Income Plan, a person is not permitted to receive a refund of accumulated contributions from the Retirement System.

• Not permitted to commence retirement benefits during receipt of benefits from the Plan.

• Earnings are permitted during the Short-Term disability period up to the amount of the Short-Term benefits without a reduction in the benefit.

• If the earnings exceed the amount of Short-Term benefit, the payment will be reduced on a dollar-for-dollar basis by the amount the earnings exceed the Short-Term benefit.

(Note: You must have approval for secondary employment).

General Information• The employee and the work unit MUST notify

DOC Personnel for instructions PRIOR to any return to work after application, approval, or receipt of Short-Term Disability benefits.

• It is the policy of DOC to consider requests for & provide reasonable work accommodations to qualified individuals with disabilities, pursuant to ADA. If the treating physician RELEASES the employee to return to work with restrictions & the employee wishes to comply with the department’s ADA policy, contact DOC Personnel.

Submit the Disability Application Package as Soon As Possible...

Since there is a 60-day waiting period, it is important to submit the disability application as soon as possible.

This would allow the employee to exhaust personal leave &/or seek Voluntary Shared Leave donations during the 60-day wait to help avoid a lapse in salary and benefits.

NOTE: DOC will NOT assume any responsibility for payment of fees for furnishing the required information to make application of benefits.

Short-Term Disability Package

Form DIP-1

Form DIP-3

RET-7A

Supporting Medical

Documents

Complete Short-Term Disability Package

Mail Short-Term Disability Package to

DOC Personnel.

NOTE: ONLY COMPLETED

APPLICATIONS WILL BE REVIEWED!!!!!

• Complete Name, SS#, & Home Address (including city, state, zip).

•“Retirement Account#” can be left blank.

• Complete Birth Date.

• Complete Home Phone & Employer (Work Location).

• Complete Business Phone (Work #) & Position Title.

Leave “Nature of Disability” blank.Check appropriate blocks regarding vacation & sick leave.

Check appropriate blocks certifying that your disability did not result from war, etc.

Employee Signature

DO NOT SIGN & DATE FORM until you are in the presence of a Notary Public. A Notary must witness your signature. The date of your signature MUST be the same as the Notary’s.

Side 2

The backside of the Form DIP-1 is completed by DOC Personnel, Disability Section.

Please leave blank.

• Complete Name, SS#, & Home Address.

•“Retirement Account#” can be left blank.

• Complete Home Phone.

• Complete Position Title & Business Phone(Work #).

Month/Day/Year

Complete “I have been absent from work from:” by entering your last day worked (Mo/Day/Yr).

Month/Day/Year

Complete “to” by entering “present” or the date of return to work (Mo/Day/Yr).

Month/Day/YearComplete “which began on” with your last day worked (Mo/Day/Yr).

“Employee Statement of Earnings” must be completed IF you have secondary employment OR are in receipt of any type of VA benefit, etc. Otherwise, write “None.”

Side 2

Employee Signature Date Sign and date the form on the backside.Take Form DIP-3 to your doctor’s office for completion of the “Physician Certification” section.

Mo/Day/Yr

Make sure your doctor/psychiatrist includes the Mo/Day/Yr you became disabled to perform your regular job.

DiagnosisMake sure doctor records a “Diagnosis.”

Make sure medical doctor signs and dates the bottom of this form (Stamped Signatures are acceptable). Forms signed by anyone other than a medical doctor/ psychiatrist will be returned. (Physician Assistants/ Psychologists are NOT acceptable).

Doctor’s Signature

Complete your Name, SS#, and Date of Birth. Leave “Retirement Number” BLANK.

Complete your last day worked (mo/day/yr) and sign the form.

Take this form to the Medical Doctor for completion of Sections A - H

(G & H are located on the back of this form).

PLEASE NOTE: • Form does NOT have to be typed if handwriting is legible.

Make sure doctor completes Section D History (3), indicating the mo/day/yr that you became unable to work.

•Do NOT have your doctor mail this form to the Retirement System (cross this out on the form). This form MUST be returned to you so you can submit it to DOC Personnel as part of your complete Disability package.

Side 2

Doctor must complete G-H.

Make sure medical doctor personally signs and dates the bottom of this form (NO STAMPED NAMES). Forms signed by anyone other than a medical doctor/ psychiatrist will be returned. (Physician Assistants/ Psychologists are NOT acceptable).Doctor’s Signature

Supporting Medical Documentation -Required Information

• Office Notes• Hospital Admission & Discharge

Summaries (if applicable)• X-Ray / Diagnostic Test Results• Treatment Rendered and

Prognosis

Your doctor must provide current medical documentation to support your disability. This may include:

Information Needed from the Work Unit...

• DC-113 Time Reports– Must show last day worked.– Must project exhaustion of Vacation/Bonus

Vacation and Sick Leave.

• Copy of the employee’s Essential Job Functions.

Mailing in Your Short-Term Disability Application Packet

• Before mailing in your disability application packet, be sure to review the Short-Term Disability Checklist.

• Make sure to submit the original copy of– Form DIP-1– Form DIP-3– Form Ret-7A– Supporting Medical

Documentation• The Completed Application

should be mailed to:

General Information & Application Process

Full Service RetirementAge 65 and 5 Years of Creditable Service

Age 60 and 25 Years of Creditable Service30 Years of Creditable Service

Early RetirementAge 50 and 20 Years of Creditable ServiceAge 60 and 5 Years of Creditable Service

Retirement Package

Form 6 Form RET-HM

Form RET-170

Complete Retirement

Package

Complete the Effective Date of Retirement, and the last Day of Employment

You MUST Retire on the 1st of the month.

Complete the Last Position Held and Last EmployerCheck Type of Retirement Applying For If applying for Disability (Faulkenbury) Retirement indicate if the RET-7A and Job Description are attached.

Sign and Date the Form. Old forms require notarization.

Complete the Name, Relationship and Birth Date of your Beneficiary if you want to receive an estimate of the monthly benefit after your death.The Employer Certification Section is completed by DOC Personnel/Payroll

Complete Personal Information (Name, Address, Date of Birth etc…)

Retirement Account # may be left blank.

Check the “New” Block

Complete Social Security #, Name, Address, and Phone Number and Gender

Check the Appropriate Block for Marital Status Check “Yes” or “No” for Medicare EligibilityCheck Appropriate Block for Type of

Contract Desired

Complete Medicare Information of Applicable

Complete Dependent Information

Only if you checked the blocks for “Retiree and Children” or “Retiree and Family”

Complete Other Insurance Information if Applicable

Check “Teachers’ and State Employees’”

Complete the desired Effective Date of Change, Sign and Date the Form

Complete Name, SS #, Address, and Phone # Retirement Account # may be left blank

Check the “New” Block if you are a New Retiree

Check “Teachers’ and State Employees’ Retirement System”

Check Either “Checking Account” or “Savings Account”

Attach a Deposit Slip or Voided Check to the FormSign and Date the Form

Mailing in Your Retirement Application Packet

• Make sure to submit the original copy of– Form 6– Form RET-HM– Form RET-170– DC-113’s, Time Reports

• The Completed Application should be mailed to:

Employee DeathsWork Unit Responsibilities

• Contact DOC Personnel Immediately with the Following Information:

– Name of Employee– Social Security Number– Date of Death

• Obtain a Certified Copy of the Death Certificate and Forward it to our office upon Receipt.

• Notify DOC Payroll (919) 716-3300

• Complete a 154S and Forward to the Separations Section of DOC Personnel

*DOC Personnel will Notify the Retirement System