North Carolina Administrative Code
Title 20 - STATE TREASURER
Chapter 02 - RETIREMENT SYSTEMS
Subchapter O - DISABILITY INCOME PLAN OF NORTH CAROLINA
Section .0100 - GENERAL ADMINISTRATION
Section 02O .0106 - EXTENDED SHORT-TERM DISABILITY APPLICATION DATE

(1) Full name;

(2) Mailing address;

(3) Email address;

(4) Telephone number;

(5) Date of birth;

(6) Member identification number assigned by the Retirement Systems Division;

(7) Last four digits of Social Security Number;

(8) Current or most recent employer;

(9) Employer contact name; and

(10) Signed and dated acknowledgement that the member has been receiving short-term benefits from the Disability Income Plan of North Carolina; is applying for extended short-term benefits; certifies that the illness did not result from active participation in a riot or actual or attempted commission of a terrorist act, felony, or intentional self-inflicted injury; authorizes health care providers to release to the Retirement Systems Division any medical records or other information about the disability; understands that a copy of such authorization will be as valid as the original; understands that the member, or the member's physician on the member's behalf, is to furnish the medical information to the Retirement Systems Division at no cost; and understands that the member cannot withdraw contributions from the Retirement System while receiving benefits under the Disability Income Plan of North Carolina.

(1) Mail to the mailing address in Rule 20 NCAC 02B .0101;

(2) Electronic mail (email);

(3) Facsimile transmission; or

(4) In person at the physical address in Rule 20 NCAC 02B .0101.