1. (a) NHRS Forms 16 and 17 shall accompany any application for non-occupational disability retirement benefits.

2. (b) The employee shall complete NHRS Form 16, by providing the following information:

   1. (1) The completion date;
   2. (2) The employee’s name:
   3. (3) The employee’s occupation;
   4. (4) The employer’s name;
   5. (5) The employer’s address;
   6. (6) The employer’s telephone number;
   7. (7) The nature of the employee’s disability;
   8. (8) A statement of the reasons why the employee can no longer perform the assigned duties; and
   9. (9) The employee’s signature.

3. (c) The employer shall complete NHRS Form 17 by providing the following information:

   1. (1) The employer’s name;
   2. (2) The employer’s address;
   3. (3) The date of completion;
   4. (4) The employee’s name;
   5. (5) The employee’s Social Security number;
   6. (6) The employee’s occupation;
   7. (7) The nature and extent of the employee’s inability to perform the assigned duties;
   8. (8) Supportive medical records;
   9. (9) The employee’s job description;
   10. (10) The name and signature of the employee’s immediate supervisor;
   11. (11) The name and signature of the agency’s highest authority; and
   12. (12) The dates of completion by the individuals identified in (10) and (11) above.

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