General Information & Application Process

1. Short-Term Disability General Information & Application Process

2. 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: REQUIREMENTS Short-Term Disability 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. • 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.

3. 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).

4. General Information Pay 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. Insurance Information

5. General Information Rules & Regulations • 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 benefitswithout 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. Earnings (Note: You must have approval for secondary employment).

6. General Information Return to Work • 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. Americans w/ Disabilities Act

7. 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.

8. Mail Short-Term Disability Package to DOC Personnel. NOTE: ONLY COMPLETED APPLICATIONS WILL BE REVIEWED!!!!! RET-7A Form DIP-1 Form DIP-3 + + + Supporting Medical Documents = Short-Term Disability Package Let's review how to complete the forms... Complete Short-Term Disability Package

9. Form DIP-1 • 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. 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. Employee Signature

10. Form DIP-1 Side 2 The backside of the Form DIP-1 is completed by DOC Personnel, Disability Section. Please leave blank.

11. Form DIP-3 • Complete Name, SS#, & Home Address. • “Retirement Account#” can be left blank. • Complete Home Phone. • Complete Position Title & Business Phone(Work #). Complete “I have been absent from work from:” by entering your last day worked (Mo/Day/Yr). Complete “to” by entering “present” or the date of return to work (Mo/Day/Yr). Month/Day/Year Complete “which began on” with your last day worked (Mo/Day/Yr). Month/Day/Year “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.” Month/Day/Year

12. Form DIP-3 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. Make sure your doctor/psychiatrist includes the Mo/Day/Yr you became disabled to perform your regular job. 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). Mo/Day/Yr Make sure doctor records a “Diagnosis.” Diagnosis Doctor’s Signature

13. Form RET-7A Complete your Name, SS#, and Date of Birth. Leave “Retirement Number” BLANK. • DoNOT 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. Complete your last day worked (mo/day/yr) and sign the form. Make sure doctor completes Section D History (3), indicating the mo/day/yr that you became unable to work. 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.

14. Form RET-7A 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

15. Supporting Medical Documentation -Required Information Your doctor must provide current medical documentation to support your disability. This may include: • Office Notes • Hospital Admission & Discharge Summaries (if applicable) • X-Ray / Diagnostic Test Results • Treatment Rendered and Prognosis

16. 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.

17. 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: Department of Correction Personnel Office Attn: Cindy Davis / Darlene Yost 214 West Jones Street MSC 4203 Raleigh, NC 27699-4203

18. Retirement General Information & Application Process

19. E L I G I B I L I T Y R E Q U I R E M E N T S Full Service Retirement Age 65 and 5 Years of Creditable Service Age 60 and 25 Years of Creditable Service 30 Years of Creditable Service Early Retirement Age 50 and 20 Years of Creditable Service Age 60 and 5 Years of Creditable Service

20. Form RET-170 Form 6 Form RET-HM + + + = Retirement Package How to Complete the Forms? Complete Retirement Package

21. FORM 6 Complete Personal Information (Name, Address, Date of Birth etc…) Retirement Account # may be left blank. 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 Employer Complete the Name, Relationship and Birth Date of your Beneficiary if you want to receive an estimate of the monthly benefit after your death. Check Type of Retirement Applying For If applying for Disability (Faulkenbury) Retirement indicate if the RET-7A and Job Description are attached. The Employer Certification Section is completed by DOC Personnel/Payroll Sign and Date the Form. Old forms require notarization.

22. Complete the desired Effective Date of Change, Sign and Date the Form Complete Medicare Information of Applicable Check the Appropriate Block for Marital Status Check Appropriate Block for Type of Contract Desired Complete Dependent Information Only if you checked the blocks for “Retiree and Children” or “Retiree and Family” Check the “New” Block Complete Social Security #, Name, Address, and Phone Number and Gender Check “Yes” or “No” for Medicare Eligibility Check “Teachers’ and State Employees’” Complete Other Insurance Information if Applicable Form RET-HM

23. Complete Name, SS #, Address, and Phone # Retirement Account # may be left blank Attach a Deposit Slip or Voided Check to the Form Check Either “Checking Account” or “Savings Account” Sign and Date the Form Check the “New” Block if you are a New Retiree Check “Teachers’ and State Employees’ Retirement System” Form RET-170

24. 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: Department of Correction Personnel Office Attn: Cindy Davis / Darlene Yost 214 West Jones Street MSC 4203 Raleigh, NC 27699-4203

25. 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