You should talk to your employer or contact the Retirement Systems, review the guides on the applicable disability forms and submit a complete disability application package to the Retirement Systems Division if you are applying for DIPNC preliminary long-term, DIPNC extended short-term or DIPNC long-term benefits. If you are applying for DIPNC short-term benefits, you should submit the package to your employer since the employer will be paying your short-term benefits.
| A complete DIPNC package for short-term and/or preliminary long-term includes: | |
| Form | Who completes this form |
| Form 701 (Requesting Short-Term Benefits Through the Disability Income Plan of North Carolina) | Member |
| Form 700 (Requesting Employer Information Required for Member Disability Income Plan Benefits) - page 1 | Employer |
| Job description | Employer |
| Form 703 (Report Earnings for Short-Term Disability Benefits Review) | Member Licensed Physician |
| Form 7A (Medical Report for Eligibility Review) | Licensed Physician |
Supporting medical documentation to include one of the following which supports your diagnosis:
| provided within six months |
Upon receipt of a complete disability application package, the Retirement Systems Division’s Disability Section will review your account to verify that you meet disability benefit eligibility requirements and schedule your file for Medical Board review.
Short-term disability is determined by your employer.
| A complete DIPNC package for extended short-term and/or long-term includes: | |
| Form | Who completes this form |
| Form 704 (Requesting Additional Benefits Through DIPNC) | Member |
| Form 700 (Requesting Employer Information Required for Member Disability Income Plan Benefits) - page 1 & 2 | Employer |
| Form 701 (Requesting Short-Term Benefits Through the Disability Income Plan of North Carolina | Member |
| Job description | Employer |
| Form 703 (Report Earnings for Short-Term Disability Benefits Review) | Member Licensed Physician |
| Form 7A (Medical Report for Eligibility Review) | Licensed Physician |
| Form 711 (Determining and Recording Short-Term Disability Benefits) | Employer |
Supporting medical documentation to include one of the following which supports your diagnosis:
| provided within six months |
Upon receipt of a complete disability application package, the Retirement Systems Division’s Disability Section will review your account to verify that you meet disability benefit eligibility requirements and schedule your file for Medical Board review.
You can provide your medical documentation directly to the Retirement Systems Division, but your employer will need to verify your employment information and provide other information on your disability forms to the Retirement Systems Division in order for your disability benefits to be processed.
Upon Medical Board approval for DIPNC extended short-term or long-term disability benefits, the Retirement Systems Division will notify you of the decision and send you all final required forms/information to be properly completed and submitted to the Retirement Systems Division to begin calculating your benefit amount. Depending on your DIPNC approval date, your first payment may be a prorated amount. If you have applied for DIPNC short-term or preliminary long-term benefits, please contact your employer for information since the employer will be paying these benefits. All forms listed can be found on ORBIT .
| A complete DIPNC package for short-term and/or preliminary long-term includes: | |
| Form | Who completes this form |
| Form 705 (Agreeing to Accept Long-Term Benefits through DIPNC | Member |
| Form 706 (Confirming an Employee's Resignation) | Employer |
| Form 716 (DIPNC or TSERS Early Service Retirement Benefit Options) | Member (if eligible) |
| Social Security Disability Notice of Awards, Veterans Administration Notice of Awards and/or Workers' Compensation Benefit Payment Information | Member |
This page was last modified on 02/28/2025