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.

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.

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.

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.

Beneficiary Designation - use this form to designate a beneficiary or beneficiaries who will receive your life insurance benefits in the event of your death.

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.

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 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.