Benefit Plan Forms

Click on the links below to download the appropriate Benefit Plans forms. If you need a form that is not listed, please call the Benefits Department at 718-430-2547.
 

Health Insurance 

• Group Health & Dental Enrollment Form   
• Out-Of-Network Claim Form 
• Express Scripts Home Delivery Order Form   

Dental Insurance 

• Group Health & Dental Enrollment Form   
• Out-Of-Network Dental Claim Form  (for Delta Dental for claims incurred in 2012)

Health Care and Dependent Care Reimbursement Account(s) 

To enroll in the Health Care Reimbursement Account please use the HCRA Enrollment module.  Click here to access the module.

HCRA/DCRA Claim Form   (EBPA claim form for 2012 expenses)

Life Insurance  

• Group Insurance Election Form 
• Group Life Insurance Beneficiary Form 
• Evidence of Insurability Form  

Transit Reimbursement & Parking Reimbursement Program (TRiP) 

• Transportation Reimbursement & Parking Reimbursement Enrollment Form    
• Transit Reimbursement & Parking Reimbursement Claim Form (EBPA claim form for 2012 expenses)
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Tax Choice Long Term Disability Insurance 

• Tax Choice Long Term Disability Election Form   

Retirement Plans 

• Basic Retirement Income Plan Salary Reduction Agreement   
• Basic Retirement Income Plan Enrollment Form  
• Basic Retirement Income Plan Beneficiary Designation Form 
•  Catch-up Contribution Form