1. (a) To apply for accidental disability retirement, every Group I or Group II member shall provide the following information:

   1. (1) An application for accidental disability retirement;
   2. (2) A tax withholding certificate;

   3. (3) A copy of the member’s Social Security card or IRS Form W-9;

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   4. (5) A copy of the beneficiary’s(ies’) birth certificate(s) if the member selects a survivorship option;
   5. (6) The Employee’s Statement of Accidental Disability;
   6. (7) A release for access to treatment records;
   7. (8) The Physician’s Medical Examination and Certification;
   8. (9) The Wage and Personnel Authorization form;
   9. (10) For Group II members only, a copy of the marriage certificate if the member is married;
   10. (11) Any other documentation requested by the system; and
   11. (12) The Special Election Provision form, if applicable.

2. (b) Every Group I or Group II member shall complete Section I and provide the following information:

   1. (1) The member’s name;
   2. (2) The member’s Social Security number;
   3. (3) The member’s mailing address;
   4. (4) The employer’s name;
   5. (5) The member’s position title;
   6. (6) The member’s home telephone number;
   7. (7) The member’s date of birth; and
   8. (8) The member’s effective date of retirement.
3. (c) Every Group I or Group II member shall select and sign only one benefit payment choice.

4. (d) Every Group I or Group II member shall designate primary beneficiaries and provide the following information:

   1. (1) The name(s) of the beneficiary(ies);
   2. (2) The mailing address(es) of the beneficiary(ies);
   3. (3) The Social Security number(s) of the beneficiary(ies);
   4. (4) The date(s) of birth of the beneficiary(ies);
   5. (5) The beneficiary(ies)’s relationship to the member, and
   6. (6) The distribution percentage in the case of multiple beneficiaries.
5. (e) Every Group I or Group II member shall designate contingent beneficiaries by providing the same information as required in (d) above.
6. (f) Every Group II member shall designate a beneficiary(ies) for the special Group II death benefits provided under RSA 100-A:12 by providing the same information that is required in (d) above.
7. (g) Every Group I or Group II member shall sign and date NHRS Form 4 and shall have it acknowledged by a Notary Public or a Justice of the Peace.
8. (h) The member shall retain the yellow copy of NHRS Form 28 or NHRS Form 30 and shall return the white copy to the system.

Source. #7574, eff 10-10-01, EXPIRED: 10-10-09 New. #9563, eff 10-14-09, EXPIRED: 10-14-17