Please choose the appropriate form(s) that you require.

All forms are in PDF format, and require Adobe Acrobat Reader.

 

 

 

Local

File Description

Form

Generic Forms

Change of Address

Click Here

 

Medical Claim Form

Click Here

 

Dental Claim Form

Click Here

 

W-9 Form

Click Here

 

 

 

Correction Officers' Benevolent Association
COBA Annuity Disbursement Form
     

Local 300 SEIU AFL-CIO Welfare Fund

Vision care claim reimbursement form

Click Here

 

Podiatry Benefit Active Members

Click Here

 

 

 

 United Staff Associates Welfare Fund

Optical Claim Form

Click Here

 

Variable Benefit Claim Form

Click Here

 

Dental Claim Form

Click Here

  Change of Address form
  Change of Status Form
 

 

 

 

Dobbs Ferry United Teachers

Benefit Claim Form

Click Here

 

Dental Form

Click Here

 

Change of Address Form

Click Here

 

 

 

East Williston Teachers Association

Dental Claim Form

Click Here

 

Hearing Aid Claim Form

Click Here

 

Medical Co-pay Reimbursement  

Click Here

 

Prescription Claim Form

Click Here

 

Supplemental Optical Form

Click Here

  Retiree Excess Medical Claim Form

Click Here

  Retiree Supplemental Optical Form

Click Here

     

Faculty Association Suffolk Community College

Prescription Claim Form

Click Here

 

 

 

Great Neck Teachers Association Benefit Trust Fund

Prescription Claim Form - Active

Click Here

 

Excess Medical Benefit Form - Active

Click Here

 

Prescription Claim Form - Retiree

Click Here

 

Excess Medical Benefit Worksheet

Click Here

 

 

 

Local 891 International Union of Operating Engineers

Plan A Optical Claim Form

Click Here

 

Prescription Claim Form

Click Here

  Variable Benefit Claim Form

 

 

 

New York State Court Clerks Association

Optical Claim Form

Click Here

  Copay Benefit Claim Form Click Here

 

 

 

United Teachers of Seaford

Benefits Summary

Click Here

 

 

 

Wappingers Congress of Teachers

Hearing Aid Claim Form

Click Here

 

Prescription Claim Form

Click Here

     

 

Manhasset Education Association

 

Dental Claim Form

 

Click Here

 

Optical Form

Click Here

 

Supplemental Form

Click Here

 

 

 

CWA 1180

Dental Claim Form

Click Here

  Disclosure Click Here

 

 

 

Tile Layers Local 7

Supplemental Medical

Click Here

 

Supplemental Benefit Unemployment

Click Here

     
New York Supreme Court Officers Association Participating Dentists Panel Click Here