Benefit Forms

 

Dental Forms

     For all Bargining Units:

• CSEA Dental Claim Form (PDF) * or (Text)
• MC Dental Claim Form (GHI) (PDF) * or (Text)
• UUP Dental and Vision Forms

Health Forms

• Civil Service Online Forms
• Regular Employee Health Insurance Enrollment Form (PS404) (PDF) * or (Text)
• HMO Enrollment Form (PDF) * or (Text)
• Graduate Student Health Insurance Enrollment Form (PDF) * or (Text)
• Empire Plan Out-of Network Claim Form (PDF) * or (Text)
• Sick Leave Credit Election (Dual Annuitant) (PDF) * or (Text)
• Deferred Health Insurance for Retirees (Indefinitely) (PDF) * or (Text)
• Sick Leave Credit Preservation (PDF) * or (Text)
• Health Insurance and Dental/
  Vision Insurance for Employees on Leave Without Pay (PDF) * or (Text)
• LWOP Health Insurance Remittance Notice (PDF) * or (Text)
• Family LWOP Health Insurance Remittance Notice (PDF) * or (Text)
• Waiver of Premium Application (PDF) * or (Text)
• Statement of Dependence (PDF) * or (Text)
• Application for a Reduced Maximum Out-of-Pocket Co-insurance Expense (PDF) * or (Text)
• Coordination of Benefits (PDF) * or (Text)
• Dependent COBRA Request Letter (DOC) or (Text)
• Dependent COBRA Request Letter (Graduating) (DOC) or (Text)

Retirement Forms

• Retirement History Form (PDF) * or (Text)
• Retirement Election Form (ORP-1) (PDF) * or (Text)
• ORP Public Retirement System Determination (ORP-4) (PDF) * or (Text)
• Retirement Plan Booklet (PDF) * or (Text)
• Salary Reduction Agreement (PDF) * or (Text)
• TIAA-CREF Retirement Forms
• Teachers' Retirement System Forms

Union Benefit Fund Forms

• CSEA
• UUP

Vision Forms

• Vision Forms
• Davis Vision Out of Network Claim Form (PDF) * or (Text)