Requesting Short-Term Benefits Through The Disability Income Plan Of North Carolina Page 3
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4Discussing Short-Term Benefits through the
Disability Income Plan of North Carolina
with Your Employer
Sign this page and submit it your employer IF your employer directs you to do so.
Guide A.
Review your record of service with your benefits representative.
(1) You are not eligible for these benefits if your illness began
(2) You must have earned at least one year (as defined by
after your effective termination date. You must have either
your contract) of contributing membership service credit in
been physically at work or receiving pay for leave (sick,
the Teachers' and State Employees' Retirement System in
vacation, bonus, annual, compensatory, or shared) or
the past 36 calendar months to be eligible for short-term
receiving temporary total Workers' Compensation benefits
benefits
through the Disability Income Plan of North
when your illness began as certified by an authorized
Carolina.
medical professional.
Guide B.
Discuss with your benefits representative the types of illnesses which may be eligible.
(1) A qualifying illness must be expected to last longer than 60
Please describe your illness and tell us how it affects your
days and continuously and directly impact the performance
ability to do your work. Attach another sheet if necessary.
of your regular duties. Your benefits representative will
provide you with the appropriate forms and a formal job
description
to
present
to
an
authorized
medical
professional.
(2) You must consult a certified medical professional
(physician, physician's assistant, family nurse practitioner,
psychiatrist, psychologist, or chiropractor) to complete
forms about how your illness impacts your duties.
Guide C.
Review the benefit period and income choices with your benefits representative.
How many days of the following types of leave would you
You may be eligible for first stage benefits for a period of up to
like to use as a means of income during the waiting
365 days after a 60-day waiting period. Returning to work may
period?
affect the waiting period or the benefit payment. You may choose
to use your accumulated leave as a means of income during the
sick
vacation
bonus
compensatory
waiting period. You may choose to use any remaining leave
shared
other allowed by your employer's policy
balance as income instead of a benefit during the first-stage
period, with the benefit available to you for the remainder of the
Of the remainder(s) of the following types of leave, which
365-day period (provided you remain eligible for benefits).
would you like to use during the benefit period?
sick
vacation
bonus
compensatory
shared
other allowed by your employer's policy
Guide D.
Discuss with your employer who will determine whether your illness qualifies you.
An authorized medical professional should advise you on the
professional. The Medical Board of the Disability Income
anticipated
length
of
your
illness,
and
your
benefits
Plan of North Carolina reviews the report, and may approve
representative should advise you how the expected length of
a waiver on the requirement to submit the updated Form 703
your illness can influence the application process.
monthly. You are required to submit the monthly Form 703
• If your illness is expected to last less than one year, you
until an approval from the Medical Board is reached.
should submit an initial Form 703 to your employer as soon as
Which approach do you believe is best for you in applying
possible, and an updated
Form 703 to your employer
for the short-term benefit?
following a monthly visit to your certified medical professional.
The updated Form 703 is due on the first of every calendar
My employer will make a choice: either review my
month until the end of the short term.
application for short-term benefits or plan to forward my
• If your illness is expected to last at least one year or longer,
application to the Medical Board.
or begins to look that way at any point during the waiting period
of the short term, you should submit a Form 7A to your
I believe my illness is permanent or I expect it to last at
employer as soon as possible. The Form 7A is a thorough
least one year, so I am seeking approval for preliminary
medical report to be completed by a certified medical
long-term benefits from the Medical Board.
Please continue to the next page.
REV 20071009
701
Signature
Date
GUIDES
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