CSS2HTML: WEB6254.XDP

BENDING

REACHING 

C.  LIFTING AND CARRYING:

WALKING

STANDING

SITTING 

A.  CHECK NUMBER OF HOURS A DAY:

DESCRIBE THE KIND AND AMOUNT OF PHYSICAL ACTIVITY THIS JOB INVOLVED DURING A TYPICAL DAY IN TERMS OF:

TITLE

SIGNATURE

Position Description Attached

DATE

NAME OF SUPERVISOR (PLEASE PRINT)

PHONE

Please call SC Retirement Systems Customer Service with any questions: (800) 868-9002 (in state) or (803) 737-6800, or cs@retirement.sc.gov

Return completed form to the SC Retirement Systems (address above).

DESCRIBE BASIC DUTIES OF JOB BELOW AND ATTACH EMPLOYEE'S POSITION DESCRIPTION.

ALSO, EXPLAIN ALL "YES" ANSWERS ABOVE BY GIVING A FULL DESCRIPTION OF:

A.  Type of machines, tools, or equipment used, and exact operations performed.

B.  The technical knowledge or skills involved.

C.  Type of writing done and nature of reports.

D.  The number of people supervised and the extent of supervision.

6.  Employer Code 

5. Employer

4. Position Title

DISABILITY APPLICANT/EMPLOYEE INFORMATION

The individual indicated below has applied for disability retirement  benefits.  Please complete the information on the remainder of this form, and return it to the address listed above as soon as possible.  Upon receipt of this completed form, the employee's application will be processed.

EMPLOYER'S DESCRIPTION OF DISABILITY APPLICANT'S JOB

(TO BE COMPLETED BY APPLICANT'S SUPERVISOR)

SC Public Employee Benefit Authority

South Carolina Retirement Systems 

ATTENTION: CUSTOMER ANNUITY CLAIMS
PO Box 11960, Columbia SC 29211-1960

Retirement System

Form 6254
Revised 7/9/2012

 

Print or type in black ink

Date employee started this position:

Date employee stopped work in this position because of disability: 

3. Social Security Number

2. First/Middle Name

1. Last Name & Suffix

1. Use machines, tools, or equipment of any kind?

2. Use technical knowledge of any kind?

3. Do any writing, complete reports, or perform similar duties?

4. Have supervisory responsibilities?

IN THIS JOB DID THE EMPLOYEE:

   THIS EMPLOYEE  FREQUENTLY (1/3 TO 2/3 OF AN 8-HOUR DAY) LIFTS AND/OR CARRIES:

Kinds of objects lifted:

     THIS EMPLOYEE OCCASIONALLY (UP TO 1/3 OF AN 8-HOUR DAY) LIFTS AND/OR CARRIES:

 

 

B.  CHECK HOW OFTEN:

MM-DD-YYYY

HANDLE, GRAB, OR GRASP LARGE OBJECTS 

WRITE, TYPE, OR HANDLE SMALL OBJECTS 

Kinds of objects lifted:

Kinds of objects lifted:

Kinds of objects lifted:

Kinds of objects lifted:

Kinds of objects lifted:

Kinds of objects lifted:

Kinds of objects lifted:

MM-DD-YYYY