You must fill out this form to initiate your Workers’ Compensation claim. You should retain one copy, file a second with the Board, and provide a third to your legal representative.

Please complete this form if you would like to cancel the Electronic Fund Transfer (EFT) or Direct Deposit of one or both of the following: a) your monthly retirement allowance under the Qualified Pension Plan (QPP); or b) your monthly annuity...

This form is for retired members who have elected a non-New York City optional rider for health insurance or prescription plan, or are covered under their spouse’s/domestic partner’s non-NYC health plan.

This price waiver form must be completed by both the member and his/her physician in cases where a brand rather than generic prescription is deemed medically necessary.

Please file this form only if you meet one or both of the following conditions: You are receiving Qualified Pension Plan (QPP) and/or Tax-Deferred Annuity (TDA) payments from TRS through Electronic Fund Transfer (EFT); and The account number at your...

These instructions explain how to fill out your dental claim form either after treatment or for pre-treatment estimates for more complicated procedures such as periodontic surgery, bridges, crowns, inlays, dentures and other procedures that cost over...

The employer is required to fill out this report within 10 days to notify the Workers’ Compensation Board of your work-related injury or illness. You should not participate in filling out this form. See the C-2: Employer's Report - Filing Procedure...

Your doctor must fill out this form at regular intervals — usually every 4-6 weeks — during your convalescence. It is used to determine your level of benefits — so it is very important that your doctor fills it out carefully.

Include all original pharmacy receipts with prescription detail clearly noted which must include the name, strength, quantity and price. Please attach to this form. Receipts must be mailed within 90 days from date of service. Reimbursement will be in...

Use the forms in this package to report occupational exposure incidents. Exposure incident means a specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious materials that results...

All pedagogical personnel may apply for a medical leave of absence without pay only when they have exhausted all of their Cumulative Absence Reserve (CAR) days. This application must be completed, signed and submitted to HR Connect for approval...

Educational paraprofessionals should use this form for initial requests for leaves of absence as well as requests for extensions. Requests for extensions must be submitted prior to the date of expiration of the current leave.

If an accommodation request is denied or cannot be provided through informal means, the employee may apply for a formal accommodation by submitting the Accommodation Request Form on page 2. Medical documentation to support the request must be...

Pedagogues and paraprofessionals use this form to apply for a retirement leave of absence. For every two days in the employee’s sick bank, one day of terminal leave is granted. The form must be filed 30 days in advance of the leave. The leave can...

This form is used by all pedagogues to apply for medical certification for absence up to 20 consecutive school days, for requests to borrow sick days, for excuse of absence due to children’s diseases, and for injury in the line of duty claims. Rules...

Use this form to decline Welfare Fund benefits for your eligible dependents. You must sign this form and have it notarized.

Use this form to decline all Welfare Fund benefits for yourself and eligible dependents. You must sign this form and have it notarized.

Use this form to decline Welfare Fund dental and/or vision benefits for yourself and eligible dependents. You must sign this form and have it notarized.

Form and instructions from the DOE Science Safety Manual.

For HIP subscribers only, use this In-Hospital Private Duty Nursing Claim Form for the UFT Welfare Fund to cover the costs, after a 72-hour deductible, of 80% of the usual and customary costs of in-hospital services provided by a registered nurse...

You can choose a personal representative(s) to share your health information with by filling out this form.

This form is used by school nurses and occupational and physical therapists.

Electronic Fund Transfer (EFT) is a payment system that allows TRS retirees and beneficiaries receiving lifetime benefits to have their monthly Qualified Pension Plan (QPP) and/or Tax-Deferred Annuity (TDA) Program payments electronically transferred...

Use this form to file a claim if your eyeglasses were damaged in an assault.

If there is equipment in your school that is unrepairable, not cost-effective to repair, educationally inappropriate, or a safety hazard, complete this form to have the equipment removed.

Upon resignation, termination or retirement, pedagogues are entitled to receive half of their sick leave balance (up to 100 days).

Complete a separate application for Young Adult Coverage for each dependent child between the ages of 26-29 for whom you are requesting coverage by the UFT Welfare Fund.

Members on an approved Child Care Leave who are currently covered by the UFT Welfare Fund are eligible to receive extended UFT Welfare Fund benefits for up to a maximum of six (6) consecutive months for the birth or adoption of a child.

You should submit this report with your Educational Paraprofessional Leave Application to prevent the disruption of your major medical insurance.