New Hampshire Code of Administrative Rules
Ret - Board of Trustees of the N.H. Retirement System
Chapter Ret 500 - FILING OF FORMS
Part Ret 502 - FORMS AND FILING REQUIREMENTS
Section Ret 502.05 - Filing NHRS Forms 28 and 30 Group I or Group II, Applications for Accidental Disability Retirement

Universal Citation: NH Admin Rules Ret 502.05

Current through Register No. 40, October 3, 2024

(a) To apply for accidental disability retirement, every Group I or Group II member shall provide the following information:

(1) An application for accidental disability retirement;

(2) A tax withholding certificate;

(3) A copy of the member's Social Security card or IRS Form W-9;

(4) A copy of the member's birth certificate;

(5) A copy of the beneficiary's(ies') birth certificate(s) if the member selects a survivorship option;

(6) The Employee's Statement of Accidental Disability;

(7) A release for access to treatment records;

(8) The Physician's Medical Examination and Certification;

(9) The Wage and Personnel Authorization form;

(10) For Group II members only, a copy of the marriage certificate if the member is married;

(11) Any other documentation requested by the system; and

(12) The Special Election Provision form, if applicable.

(b) Every Group I or Group II member shall complete Section I and provide the following information:

(1) The member's name;

(2) The member's Social Security number;

(3) The member's mailing address;

(4) The employer's name;

(5) The member's position title;

(6) The member's home telephone number;

(7) The member's date of birth; and

(8) The member's effective date of retirement.

(c) Every Group I or Group II member shall select and sign only one benefit payment choice.

(d) Every Group I or Group II member shall designate primary beneficiaries and provide the following information:

(1) The name(s) of the beneficiary(ies);

(2) The mailing address(es) of the beneficiary(ies);

(3) The Social Security number(s) of the beneficiary(ies);

(4) The date(s) of birth of the beneficiary(ies);

(5) The beneficiary(ies)'s relationship to the member, and

(6) The distribution percentage in the case of multiple beneficiaries.

(e) Every Group I or Group II member shall designate contingent beneficiaries by providing the same information as required in (d) above.

(f) Every Group II member shall designate a beneficiary(ies) for the special Group II death benefits provided under RSA 100-A:12 by providing the same information that is required in (d) above.

(g) Every Group I or Group II member shall sign and date NHRS Form 4 and shall have it acknowledged by a Notary Public or a Justice of the Peace.

(h) The member shall retain the yellow copy of NHRS Form 28 or NHRS Form 30 and shall return the white copy to the system.

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

New. #9563, eff 10-14-09

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