N.H. Admin. Code § Ret 502.09

Current through Register No. 44, October 31, 2024

Section Ret 502.09 - Filing of NHRS Forms 7 and 8, Employee's and Employer's Statement of Accidental Disability

(a) NHRS Forms 7 and 8 shall accompany any application for occupational disability retirement benefits.

(b) The employee shall complete NHRS Form 7 by providing the following:

(1) The date of completion;

(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 place, date and time of injury;

(8) The nature and cause of injury;

(9) The history of initial treatment;

(10) The employee's date of return to work; and

(11) The employee's signature.

(c) The employer shall complete NHRS Form 8 by providing the following:

(1) The date of completion;

(2) The employer's name;

(3) The employer's address;

(4) The employee's name;

(5) The employee's Social Security number;

(6) The employee's occupation;

(7) The date, time, place, cause and nature of the employee's injury;

(8) A list of witnesses;

(9) An indication whether:

a.The incapacity is a result of repeated trauma, gradual degeneration, occupational disease or stress;

b.The member is required to perform any duties that are not specifically identified in the job description;

c.The duties or the work environment have been modified to accommodate the member;

d.The duties or the work environment can be modified to accommodate the member; and

e.The applicant is in receipt of workers' compensation benefits, and if so, the date payments commenced;

(10) Medical reports related to the injury;

(11) The employee's job description;

(12) Statements from witnesses, if applicable;

(13) NH department of labor workers' compensation injury reports and benefit payment records;

(14) The name, title, signature of the employee's immediate supervisor;

(15) The name, title, signature of the agency highest authority; and

(16) The dates of the certifications by the individuals identified in (14) and (15) above.

N.H. Admin. Code § Ret 502.09

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

New. #9563, eff 10-14-09