Enrollment Forms

Delta Dental Enrollment Form

Delta Disenrollment Form

Optional Disability Rider Enrollment Form

Optional Disability Rider Medical Questionnaire

Dependent Student Enrollment Form 
For F/T students age 19 through 23.

Adjunct Health Coverage 
Requires sign-off by College Benefits Office

Adjunct Cobra Enrollment

Adjunct Vision Program (GVS)

Catastrophic Major Medical

Payroll/Pension Deduction Authorization forms

NYSUT Payroll Deduction Authorization 
This Form is required to pay premiums on any of these voluntary benefits: Life Insurance (after the first year), Catastrophic Medical Coverage and Long-Term Care..  It may also used to pay for other benefits through the NYSUT Benefit Trust. This Form is to be returned to the appropriate party to assure the correct process.

NYSUT Pension Deduction Form 
To pay premiums on voluntary benefits (e.g. Catastrophic Medical Coverage and Long-Term Care).

REIMBURSEMENT CLAIM FORMS

Dental Claims

Delta. Members of Delta Dental do not need Claim Forms for regular care.  Emergency Claim Forms (Reimbursed up to $100) are available from Delta here.

Guardian Non-Participating Dentist Form

Retirees.  Certain (Plan 70 and 80) retirees (see the SPD) are eligible only for a dental reimbursement.  (This does not apply to most retirees, who participate in either the Delta or Guardian plans above.)

Dental Reimbursement Form For Plan 70 Retirees

Dental Reimbursement Form For Plan 80 Retirees

Drug Claims

Medco.  Members of Medco either use their Drug Card at a pharmacy or use Mail Order.  The most cost-effective way to buy long-term medications is to use Mail Order.

Medco Mail Order Form

If covered, but drugs were purchased, a Reimbursement Form is used.

Medco Reimbursement Form

Retirees.  Certain retirees (see the SPD) are eligible only for a drug reimbursement.  (This does not apply to most retirees, who participate in Medco or other plans.)

Prescription Drug Refund Form For Plan 70 and Plan 80 Retirees

Disability Claims

Claim forms are available from Standard Life Insurance Company,

tel. # 1-888-689-1698

Extended Medical Claim Forms

GHI Extended Benefit Form

Covered Members need to complete the Claim Form and attach information noted

Hearing Aid

Hearing Aid Reimbursement Form

Optical

No Claim Form is necessary when using General Vision Services or Davis Vision.

Direct Reimbursement for Other Qualified Vision Care

GVS $100 Bonus Check Towards an Additional Pair of Glasses

Catastrophic Medical

Claim Forms for Catastrophic Medical are available from Marsh 1-800-503-9230. (Marsh is creating a special web link for CUNY faculty and staff.  Once the page(s) are created, we will provide the link.)

Long Term Care

Claim Forms for Long-Term Care are available from John Hancock, 1-888-513-2071 (Hancock is creating a special web link for CUNY faculty and staff.  Once the page(s) are created, we will provide the link.)   

Wellness

Weight Watchers Reimbursement Form 
               

INSURANCE CERTIFICATES

Extended Disability Certificate

BENEFICIARY DESIGNATION FORMS

Death Benefit Beneficiary Designation Form