Forms

Forms for Enrolling
Welfare Fund Benefits	Send To
WF Supplemental Benefits Enrollment Form	Your Campus Benefits Office
WF Adjunct Family Enrollment Supplement Form	Your Campus Benefits Office(s)
WF Supplemental Benefits Application for Domestic Partner	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Delta Dental Enrollment Form	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Delta Dental Disenrollment Form	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Optional Benefits	Send To
Extended Long Term Disability Enrollment Form	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Medical History (NY) Medical History (NJ) Medical History (CT) Medical History (PA)	The Standard Life Insurance Company of New York Medical Underwriting 900 SW Fifth Avenue Portland, OR 97204
Term Life Application and Policy	Marsh U.S. Consumer, a Service of Seabury & Smith, Inc. P.O. Box 9186 Des Moines, IA 50306-9186
Catastrophic Major Medical Insurance Application (Enrollment is currently closed.)	Administrator PSC-CUNY Group Insurance Program P.O. Box 10374 Des Moines, IA 50306-0374
Payroll Deduction Authorization Pension Deduction Authorization	Administrator PSC-CUNY Group Insurance Program P.O. Box 10374 Des Moines, IA 50306-0374
NYC Basic Benefits	Send To
NYCHBP Application	Actives: Campus Benefits Office Retirees: City of New York Health Benefits Program 40 Rector Street - 3rd Floor New York, New York 10006

Forms For Claiming Benefits
Welfare Fund Benefits	Send To
Guardian Claim Form	Group Dental Claims PO Box 2459 Spokane, WA 99210
Delta Dental Claim Form	Delta Dental of New York, Inc PO Box 2105 Mechanicsburg, PA 17055
Dental Reimbursement Form (Retiree Plan 70)	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Dental Reimbursement Form (Retiree Plan 80)	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Prescription Drug Claim Form	Medco Health Solutions, Inc. PO Box 14711 Lexington, KY 40512
Direct Optical Reimbursement Form	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY10006
Prescription Drug Reimbursement Form (Retiree Plan 70)	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY10006
Extended Medical Benefit Claim Form	Administrative Services Only, Inc Department # 178 P.O. Box 9009 Lynbrook, NY 11563-9009
Hearing Aid Reimbursement Form	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Weight Watchers Claim Form	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Optional Benefits	Send To
Catastrophic Major Medical Insurance Claim Form	The United States Life Insurance Company 3600 Route 66 P.O. Box 1581, MSN 2-E Neptune, NJ 07754-1581

Other Forms
	Send To
Medco By Mail Order Form	Medco Health Solutions of Dallas P.O. Box 650322 Dallas, TX 75265-0322
Beneficiary Designation Card	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Parental Leave Application	Chair/unit head for approval and then forward approved leave to the Human Resources Department
Medicare Part B Reimbursement for TIAA-CREF retirees	The City University of New York University Employee Benefits Office 395 Hudson St., 5th floor New York, NY 10014
Medicare Part B IRMAA Surcharge Reimbursement (2013)	Office of Labor Relations Health Benefits Program 40 Rector St., 3rd floor New York, NY 10006
Welfare Fund Adjunct COBRA Continuation Enrollment	PSC-CUNY Welfare Fund 61 Broadway, 15th floor New York, NY 10006
Welfare Fund COBRA Continuation Enrollment	PSC-CUNY Welfare Fund 61 Broadway, 15th floor New York, NY 10006
Healthcare Proxy info, form & instructions	The New York Health Care Proxy Law allows you to appoint someone you trust - for example, a family member or close friend - to make health care decisions for you if you lose the ability to make decisions yourself.

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