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CCNY Benefits Forms

Human Resources

CCNY Benefits Forms



Adjuncts are eligible for health benefits as a Teaching or Non-Teaching Adjunct, if you meet the
following eligibility requirements:

Teaching Adjunct: Completed two (2) consecutive semesters of at least one or two courses per
week of Adjunct instruction for the full semester at CUNY immediately prior to the current
semester; teaching at least six (6) hours per week for the full semester, which must be

Non-Teaching Adjunct: Completed two (2) consecutive semesters of at least 15 hours per week
for the full semester at CUNY immediately prior to the current semester working at least 15 hours
per week for the full semester;.
Note: The summer or winter "session" is not considered towards meeting the eligibility

Be Advised:

If you are currently not covered or eligible to be covered by any other health insurance plan by
virtue of employment of self, spouse or through government entitlement, then you may be
eligible to be enrolled in health benefits through the New York City Health Benefits Program
administered through the CUNY University Benefits Office.

The enrollment forms can be obtained from the site below and your Benefits Officer will need to verify that the eligibility
requirements have been met. If eligibility is due to your employment at two campuses, you will be
required to obtain verification from each campus. Some employee health plans are available free of
charge, and dependent health insurance coverage is available through premium payment. For
detailed information, visit the UBO website, under Benefits at a Glance-> Adjuncts
Teaching and Non-Teaching.

Adjunct Health Benefits Forms

Adjunct GHI-CBP Individual Summary of Coverage

Adjunct HIP Prime HMO Individual Summary of Coverage

PSC-CUNY WELFARE FUND Eligibility for Adjuncts

PSC-CUNY Adjunct FAQ Sheet

Adjunct Health Benefits Packet

Alternative Coverage: Insurance Marketplace


Full-Time Faculty and Staff Benefits Forms

Health Benefits Application

Health Plan Rate Sheet

Summaries of Coverage


Retirement Forms

Full-Time Teaching and Non-Teaching Instructional Staff

Teacher's Retirement System Application

PSC-CUNY Choosing a Retirement Plan Info Sheet

Retirement Election Form

Retiree E-Mail Form

Phased Retirement Program

Phased Retirement Summary

Phased Retirement Application - Faculty

Phased Retirement Application - Professional Staff

Phased Retirement Signed Agreement

Classified Staff

NYCERS Enrollment Application


Voluntary Retirement Forms- 2018 Salary Reduction Aggreement 

Full-Time Teaching and Non-Teaching Instructional Staff


NYS Deferred Compensation

Haliday Financial



Dedicated/Catastrophic Sick Leave Policy

Dedicated Annual/Sick Leave Program
Catastrophic Sick Leave Bank Program (CSLB)
(Application to Donate and Application to Receive)


Transit Benefit Forms

MARCH 2017
Attention all WageWorks Transit Benefits Participants:
Effective March 19, 2017, an MTA approved fare hike will go into effect. This will will affect the MetroCard 30-day/7-day unlimited, Pay Per Ride, Access-a-Ride, Long Island Railroad and the Metro-North Railroad. The new rate list can be found on the MTA Website. Please be advised; the monthly pre-tax limit is $260.00. Deductions that exceed this amount will be subject to taxes.
Employees who wish to adjust their deductions accordingly, enroll in the program, suspend their payroll deductions, or cancel their participation in the Commuter Benefits Program, can download, fill out and submit a WageWorks form to the HR Office, Shepard Hall, Room 50. Please be advised that changes to your WageWorks deductions may take up to 2 pay periods to take effect.


If you have any questions, please contact Kim Ferguson at 212-650-7963, or by email at

WageWorks Form



NEW Health Insurance Marketplace Coverage Options and Your Health Coverage

New Health Insurance Marketplace Coverage Options and Your Health Coverage (Non tax levy)



Other Forms

City Health Plans Dependent Eligibility Verification Audit
Dependent Eligibility Verification Audit FAQs

Important Pension Information – New Tier VI in effect April 1, 2012

COBRA Information/Continued Coverage Application
(Please be advised that this form must be filled out by the Benefits Officer prior to submission. Please call x7963 for assistance with COBRA enrollment.)

Important Phone Numbers

Classified Staff Contact Sheet

Instructional Staff or Non Instructional Staff Contact Sheet

Related Links