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 502.08 - Filing of NHRS forms 16 and 17, Employee's and Employer's Statement of Ordinary Disability
Universal Citation: NH Admin Rules Ret 502.08
Current through Register No. 12, March 21, 2024
(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.
#7574, eff 10-10-01, EXPIRED: 10-10-09
New. #9563, eff 10-14-09
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