Benefit Forms
Click on the links below to download the appropriate form. If you need a form that is not listed, please call the University Benefits Office at (646) 592-4340. Please submit forms to the Benefits Office.
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- Aetna Medical Claim Form - use this form to submit a claim to Aetna if you have used a non-participating provider.
- CVS Caremark Mail Service Order Form - use this form to order your prescriptions through CVS Mail Service.
- Aetna Vision Claim Form - use this form to claim reimbursement for expenses incurred at a non-participating provider.
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Delta Dental Claim Form - use this form to submit a claim to Delta Dental if you have used a non-participating provider.
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- HRA (Health Reimbursement Claim Form) - use this form to submit eligible health care expenses
- Health Care Reimbursement Claim Form - use this form to submit eligible health care expenses or log into your account at www.HealthEquity.com/WageWorks to submit your claim electronically.
- Dependent Care Reimbursement Claim Form - use this form to submit eligible dependent care expenses or log into your account at www.HealthEquity.com/WageWorks to submit your claim electronically.
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- Beneficiary Designation - use this form to designate a beneficiary or beneficiaries who will receive your life insurance benefits in the event of your death. You can also enter your beneficiaries onto the Benefitfocus enrollment platform.
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- 403(b) Salary Reduction Agreement 2025 - use this form to designate a percentage of your salary that you wish to contribute to the plan. You may change your salary reduction agreement at any time.
- Salary Reduction Agreement Catch-Up Plan - use this form if you are age 50 or will turn age 50 by the end of the calendar year to elect an additional catch-up contribution to the plan. You must be contributing the maximum to the Basic Plan to be eligible to elect the catch-up contribution.
- 403(b) Retirement Income Plan Enrollment Form - use this form to make investment elections for contributions to the Basic Plan.
- Retirement Income Plan Beneficiary Form - use this form to designate a beneficiary(s) or who will receive your retirement benefits if you die.
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- 403(b) Salary Reduction Agreement 2025 - use this form to designate a percentage of your salary that you wish to contribute to the plan. You may change your salary reduction agreement at any time.
- 403(b) Salary Reduction Agreement - Catchup 2025 - use this form if you are age 50 or will turn age 50 by the end of the calendar year to elect an additional catch-up contribution to the plan. You must be contributing the maximum to the Basic Plan to be eligible to elect the catch-up contribution.
- 403(b) Retirement Income Plan Enrollment Form - use this form to make investment elections for contributions to the Basic Plan.
- Retirement Income Plan Beneficiary Form - use this form to designate a beneficiary(s) or who will receive your retirement benefits if you die.
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- Pet Assure Brochure - gives you information on the plan benefits.
- Enrollment form - use this form to enroll for discounted veterinary services.
- Termination - use this form to cancel coverage.
