Full-Time Faculty and Staff Benefits Forms
Health Benefits Forms
- HEALTH PLAN COVERAGE FOR EMPLOYEES HIRED ON OR AFTER JULY 1, 2019
- HIP HMO Preferred Plan Service Area Zip Codes
- City of New York – New Employee HIP HMO Opt-Out Request Form
- Health Insurance Information
- Choosing a Health Plan
- NYC Health Insurance Summary Plan Description
- Domestic Partners to City Health Plan Coverage
- Dependent Eligibility Required Documentation
- Health Benefits Application
- November 2019 and January 2020 Basic Plan and Optional Rider Rate Sheet
- Health Benefits Buy Out Waiver Application - 2020 (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) - January 2019
- Young Adult Option Through Age 29 (NYS Law Chapter 240) - July 2019
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 Frequently Asked Questions (FAQs)
- 2020 Flexible Spending Account Application
- 2020 MSC Buy-Out Waiver Program Application (Return with health benefits enrollment application,marriage/birth certificates and proof of non City health coverage)
- Health Benefits Application
- 2020 Dependent Care Assistance Program (DeCAP)
- 2020 Health Care Flexible Spending Account (HCFSA)
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
- 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
- NYCERS.org
Voluntary Retirement Forms
TIAA
- TIAA 2019 Salary Reduction Aggreement
- 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
Transit Benefit Forms
- WageWorks Transit Benefit Enrollment Form
- About WageWorks
- Commuter Benefit Program Overview
- Which Commuter Benefit Program is right for you?
- Commuter Card Plan
- Transit Pass Plan
- Park-N-Ride Plan
- Access-A-Ride/Paratransit Plan
- Park-N-Ride Plan Enrollment Form
- Commuter Benefits Terms and Conditions
- Campus Benefit Officer/Transit Benefit Coordinator Contacts
Employees participating in the WageWorks transit benefit program will need to review their commuting costs. Effective Sunday, April 21st, 2019, the MTA New York City Transit (“MTA NYCT”) will be raising the fares of various MTA NYCT products including but not limited to the 30-Day Unlimited Ride MetroCard from $121.00 to $127.00 per month.
Fare increases will also take effect for the MTA Metro North Rail Road and Long Island Rail Road trips.
No automatic or mass changes will be processed. To update or cancel their Wage Works deductions, employees must submit a new form.
The WageWorks form can be found on the CCNY Human Resources website: WageWorks Transit Benefit Plan or obtained from The Office of Human Resources located in Shepard Hall Room 50.
For additional information regarding the MTA New York City Transit fare increase, please visit their website at https://new.mta.info/fares/2019-fare-and-toll-changes/new-fares.
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
