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 benefits for your 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.

This form allows health care providers who have treated your previous injuries to release information to your employer’s workers’ compensation insurer.

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...

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...

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...

Save more than $200 each year in taxes by participating in the city’s TransitChek program.

Summary comparison of health plans for employees and those retirees not eligible for Medicare.

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.

This is your Medicare Part D Reimbursement Claim Form, for retired members and their spouses/domestic partners.

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...

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...

See Chancellor's Regulation A-443 for information on student disciplinary procedures and student removal.

Brochure for Dentcare HMO

Social Security (FICA) and Medicare tax rates, including the maximum Social Security withholding amount per calendar year. Social Security deduction amounts will decrease, and/or stop entirely, when the maximum amount is reached. There is no maximum...

As of Oct. 2024, DOE employees not enrolled in direct deposit and are not in the H/Z bank payroll system will have their checks mailed to their address on file with the DOE directly from JP Morgan Chase bank. The NYCPS Bureau of Check Management will...

For UFT members in the Florida area, this is the Schedule of Benefits. When you use a UFT Welfare Fund participating dentist, you will be provided with the services listed in the Schedule of Covered Dental Expenses without charge except for those few...

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

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...

Read this notice of privacy practices to understand how protected health information about you may be used and disclosed and how you can get access to this information.