Full-Time Faculty and Staff Benefits Forms
Health Benefits Forms
- July 2021 Basic Plan and Optional Rider Rate Sheet
- Choosing a Health Plan
- Health Insurance Information
- NYC Health Insurance Summary Plan Description
- HIP HMO Preferred Plan Service Area Zip Codes
- City of New York – New Employee HIP HMO Opt-Out Request Form
- Domestic Partners to City Health Plan Coverage
- Dependent Eligibility Required Documentation
- Health Benefits Application
- Health Benefits Buy Out Waiver Application - 2022 (Return with health benefits enrollment application, marriage/birth certificates and proof of non City health coverage)
- Young Adult Option Through Age 29 (NYS Law Chapter 240) - July 2021
Family Medical Leave Act (FMLA) Policy and Information
- FMLA Policy
- Request Form
- Healthcare Provider Form
- Healthcare Provider Form (for the care of Family Member)
- Certification of Family Relationship (for the care of Family Member)
- Fitness for Duty Certification
Paid Parental Leave
Flexible Spending Accounts Program
The Flexible Spending Program allows City employees to deposit a portion of their pre-tax income into accounts maintained for certain health and dependent care expenses not covered by insurance. Employees covered by a non-City group health plan can enroll in the MSC Buy-Out Waiver Program and waive City health benefits to receive an incentive payment, up to $1,000 per year.
- Flexible Spending Accounts Overview
- Flexible Spending Accounts Educational Videos
- FSA Program Guides, Brochures & Forms
- FSA Frequently Asked Questions (FAQs)
- 2022 Flexible Spending Account Application
- Dependent Care Assistance Program (DeCAP)
- 2021 DeCAP Claims Form
- 2022 DeCAP Claims Form
- Health Care Flexible Spending Account (HCFSA)
- 2021 HCFSA Claims Form
- 2022 HCFSA Claims Form
Full-Time Teaching and Non-Teaching Instructional Staff
Phased Retirement Program
- Phased Retirement Summary
- Phased Retirement Application - Faculty
- Phased Retirement Application - Professional Staff
- Phased Retirement Signed Agreement
- NYCERS Enrollment Application
- Designation of Guardian – When Designating a Minor as a Beneficiary
- Designation of Primary and Contingent Beneficiary – Tier 3, Tier 4, and Tier 6
- How to Sign Up for MyNYCERS
- Buy-Back – Purchasing Credit for Service Rendered Prior to NYCERS Membership
- Change of Address
- Name Change Application
Voluntary Retirement Forms
- TIAA 2021 Salary Reduction Agreement
- TIAA 2022 Salary Reduction Agreement
- CUNY TIAA Plan Information and Enrollment Portal (Optional Retirement and Voluntary Plans)
NYS Deferred Compensation
Dedicated and Catastrophic Sick Leave Programs Policy
- Dedicated Sick Leave Program and Forms
- Dedicated Sick Leave – Application to Donate
- Dedicated Sick Leave – Application to Receive
- Catastrophic Sick Leave Bank Program (CSLB)
- Catastrophic Sick Leave Bank Program – Application to Donate Sick Leave
- Catastrophic Sick Leave Bank Program – Application to Receive Sick Leave
- Catastrophic Sick Leave Bank Program – Application to Change Donation or Withdraw
New Edenred Transit Benefit Forms and Transition Guide:
Effective March 2020, The City University of New York is changing commuter benefits providers from WageWorks to Edenred Commuter Benefits Solutions. Edenred Commuter Benefits Solutions (your new commuter benefits provider) has already begun sending important communications to all existing WageWorks participants who currently have active transit-related payroll deductions. These communications include information about what to expect in the coming weeks, how to register for a new online account to monitor your transit-related activity, when to place transit pass orders (for Transit Pass and Park-N-Ride participants only) and the new prepaid MasterCards (for Commuter Card participants only).
Be sure to open, read and retain all communications from Edenred Commuter Benefits Solutions to ensure the smoothest possible transition of your commuter account.
Commuter Benefits – Temporary Deduction Suspension Option
- Employees enrolled in the Commuter Benefits program who are temporarily working from home and don’t anticipate using the funds in their Commuter Account can opt to suspend their payroll deductions. Commuter Benefits deductions can be suspended for a period of up to one year.
- Employees can suspend their Commuter Benefits payroll deductions by completing the attached enrollment form and marking the “Suspend Deduction” option in the “Employee Action Box” at the top.
- For employees enrolled in the Park-N-Ride plan, the parking plan must be suspended for the same period. Please note this will only suspend payroll deductions. To also suspend Transit Pass orders, employees must do so directly with Edenred at (833) 584-8109 or online at login.commuterbenefits.com.
- All Commuter Benefit program participants can check their Commuter Account balance on the Edenred website.
Commuter Benefit Plans and Forms
- Commuter Card (Unrestricted) Plan – The Commuter Card is a stored value card loaded with your pre-tax and post-tax payroll deductions that can be used to purchase transit passes and tickets at transit providers throughout the New York Tri-State area. This card works just like a debit card at transit provider ticket vending machines, ticket windows and online/web stores. It can also be used to apply for MTA programs such as the Reduced-Fare MetroCard and EasyPayXpress. Your card is funded with your payroll deductions each pay date. Commuter Card – Unrestricted participants pay a post-tax administrative fee of $1.25 per month through payroll deductions.
- Transit Pass Plan – This plan allows you to arrange for home delivery of your transit provider passes and tickets through Edenred. You can select from their extensive catalog of transit providers and transit passes covering the New York Tri-State area. In this plan, you fund an Edenred account with your pre-tax and post-tax payroll deductions, and you can select a pass on the Edenred system using the funds in your account. Edenred will deliver your pass or ticket to your designated mailing address by the 1st day of each calendar month. Edenred also allows you to securely supplement purchases on their website with your personal credit card to ensure you always have enough funds for your purchases. And you can purchase multiple items such as a train tickets and MetroCard. Transit Pass participants pay a post-tax administrative fee of $2.05 per month through payroll deductions.
- Access-A-Ride/Paratransit Plan – This plan allows you to participate in Access-A-Ride if you are an employee who receives paratransit service from MTA New York City Transit. In this plan, you fund an Edenred account with your pre-tax and post-tax payroll deductions and you can select your Access-A-Ride coupons or other paratransit options via the Edenred system using the funds in your account. Edenred will deliver your Access-A-Ride coupons or tickets to your designated mailing address by the 1st day of each calendar month. Access-A-Ride Plan participants pay a post-tax administrative fee of $2.05 per month through payroll deductions.
- Edenred Park-n-Ride Benefit Enrollment Form
- Park-n-Ride Plan – This plan allows you to use your pre-tax and post-tax payroll deductions to pay for parking at or near a public transportation stop or station that you use to commute to work. Only transit-related parking is eligible. You must be jointly enrolled in one of the above transit options in order to enroll in this option. As a Park-N-Ride enrollee, you elect how your monthly parking expenses will be paid via one of the three sub-plans available (1. “Direct Pay” -Edenred pays your parking merchant directly, 2. “Parking Cash Reimbursement” - you submit claims to be reimbursed for out-of-pocket parking payments, and 3. “Parking Card” which is a stored value card that works like a debit card only for parking merchant transactions). Park-N-Ride plan participants pay a post-tax administrative fee of $2.05 per month through payroll deductions in addition to the administration fee associated with the commuter plan (Commuter Card Unrestricted/Transit Pass) chosen.
Commuter Card Admin Fee
Transit Pass/Access-A-Ride Admin Fee
Park-N-Ride Admin Fee
Transit Benefit Program Edenred NYC MTA Product Return Policy
Edenred Commuter Benefit Solutions (Edenred) provides the following Return Policy for NYC Metropolitan
Transportation Authority (MTA) products ordered from Edenred via the Commuter Benefits Program Transit Pass plan.
MTA MetroCards (return accepted anytime)
Unopened MetroCards can be returned to Edenred at PO Box 540515, Waltham, MA 02454
MTA Long Island Rail Road (LIRR) / Metro North Rail Road (MNRR)
Returns are handled directly with the transit authority. Visit their website for more information.
Long Island Rail Road: https://new.mta.info/fares-and-tolls/long-island-rail-road/long-island-rail-road/refunds
Metro North: http://web.mta.info/mnr/html/ticketrefund.htm
Participating employees can review their Commuter Benefits Program information and account balances at any time on the Edenred Commuter Benefit Solutions website login.commuterbenefits.com or by calling the Edenred Customer Service Center at 1-833-584-8109, 8:00 a.m. – 8:00 p.m.*
Other Information and 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.)
- NEW Health Insurance Marketplace Coverage Options and Your Health Coverage
- New Health Insurance Marketplace Coverage Options and Your Health Coverage (Non tax levy)
Important Phone Numbers
Last Updated: 01/28/2022 09:16