N.H. Admin. Code § Ret 502.08

Current through Register No. 50, December 12, 2024

Section Ret 502.08 - Filing of NHRS forms 16 and 17, Employee's and Employer's Statement of Ordinary Disability

(a) NHRS Forms 16 and 17 shall accompany any application for non-occupational disability retirement benefits.

(b) The employee shall complete NHRS Form 16, by providing the following information:

(1) The completion date;

(2) The employee's name:

(3) The employee's occupation;

(4) The employer's name;

(5) The employer's address;

(6) The employer's telephone number;

(7) The nature of the employee's disability;

(8) A statement of the reasons why the employee can no longer perform the assigned duties; and

(9) The employee's signature.

(c) The employer shall complete NHRS Form 17 by providing the following information:

(1) The employer's name;

(2) The employer's address;

(3) The date of completion;

(4) The employee's name;

(5) The employee's Social Security number;

(6) The employee's occupation;

(7) The nature and extent of the employee's inability to perform the assigned duties;

(8) Supportive medical records;

(9) The employee's job description;

(10) The name and signature of the employee's immediate supervisor;

(11) The name and signature of the agency's highest authority; and

(12) The dates of completion by the individuals identified in (10) and (11) above.

N.H. Admin. Code § Ret 502.08

#7574, eff 10-10-01, EXPIRED: 10-10-09

New. #9563, eff 10-14-09