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. Contact Us Artificial Intelligence Biotechnology Computer Science Cybersecurity Data Analytics and Visualization Digital Marketing and Media Mathematics Occupational Therapy Physician Assistant Physics Speech-Language Pathology Health Insurance 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. Dental Insurance Delta Dental Claim Form - use this form to submit a claim to Delta Dental if you have used a non-participating provider. MetLife Dental Claim Form - use this form to submit a claim to MetLife if you have used a non-participating provider. MetLife Dental was our carrier from January 1, 2022, through December 31, 2022. HSA/FSA/HRA Reimbursement Accounts 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 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 to submit your claim electronically. Life Insurance Form Beneficiary Designation - use this form to designate a beneficiary or beneficiaries who will receive your life insurance benefits in the event of your death. Reasonable Work Accommodations Reasonable Accommodation Policy Reasonable Accommodation Instructions Reasonable Accommodation Request Form Reasonable Accommodation Health Care Provider Release Form Reasonable Accommodation Health Care Provider Statement Form Retirement Plan 403(b) Salary Reduction Agreement 2024 - 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. High Schools Retirement Plan 403(b) Salary Reduction Agreement 2023 and 2024- 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 Supplemental 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. Pet Assure 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.
