• Benefits

Ending Employment Forms

• COBRA Notice of Rights and Health Benefit Rates
• DC 37 (link to another site)
• PSC CUNY (link to another site)
• ARRA COBRA Application (PSC CUNY)
• Travia Leave Application

FMLA Forms

• Request for Family Medical Leave (FML)
• CUNY Certification of Health Care Provider for Employees Serious Health Condition form
• CUNY Certification of Health Care Provider for Family Members Serious Health Condition form
• CUNY Certification of Qualifying Exigency for Military Family Leave form
• CUNY Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave form
• Paid Parental Leave (PSC only)

Other Benefits Forms

• Domestic Partnership Packet
• Hearing Aid
  • Hearing Aid Reimbursement Form
• GHI Health & Wellness GHI Discount Programs
• Long-Term Disability Benefits Claim Packet (PSC CUNY)
• Retiree Change of Address Form
• Series I Bond
• Series EE Bonds
• Short-term Disability Benefit Claim Form (DC 37)
• TIAA-CREF Contributions on Multiple Positions Form
• TransitBenefit Transportation Spending Account (TSA) Enrollment Form - Community Colleges
• TransitBenefit FAQ
• Wellness
  • Weight Watchers Reimbursement Form

Pre-Tax Savings Plans

• HRC Salary Reduction form
• MetLife Salary Reduction form
• New York 529 College Savings Enrollment Application
• New York 529 College Savings Payroll Deduction form
• TIAA Salary Reduction form

Retirement Forms

• Application for Retirement
• PSC-CUNY: Retiree Enrollment Questionnaire
• Retiree Change of Address Form
• Monthly Health Plan Rates- Medicare and Non- Medicare Eligible Retirees and Their Dependents
• TIAA-CREF Medicare-Eligible Retirees Application for Medicare (Part B) Reimbursement

Worker’s Compensation Forms

     Employees should be filled out with a dark pen and legible (please print).

• Worker’s Compensation Election of Options (DP-2002)
• Worker’s Compensation Employee Incident Report
• Worker’s Compensation Employee's Statement of Injury

     Supervisors must fill out and forward to HR the following forms within 48
     hours of the injury/illness:

• Worker’s Compensation Accident Description Codes
• Worker’s Compensation Supervisor's Report of Injury
• Worker’s Compensation Witness Statement