SUNY Brockport Benefits Forms (alphabetical)

 

Blue Choice Tefr/Defra Form (Medicare Secondary)

Blue Choice Change in Status Form

CSEA Employee Recognition Award Program

Dental Claim Forms

Domestic Partner Affidavit

Employee Appreciation Day Evaluation

Employees Retirement System Forms

HMO Enrollment Form

ING Loan Form (1-7-04)

LifeWorks Material Order Form

Long Term Disability Application Form (Standard Insurance Company)

NYS Health Insurance Transaction Form (PS-404)
*Please note: If joining a health plan other than Empire, an HMO enrollment form must be obtained from the Office of Human Resources. To request one please contact the Office of Human Resources at 585-395-2126.

NYS Health Insurance Transaction Form For Graduate and Teaching Assistants ONLY

Productivity Enhancement Program - PEP - (Vacation/Personal Accrual Exchange for Clerical/Maintenance)

Productivity Improvement Program - PIP - (Vacation Accrual Exchange for UUP non-faculty and M/C Professional Employees)

Preferred Care Change in Status Form

Retirement Forms (New Employee): Graduate Assistants/Teaching Assistants

Separation Checklist

Sick Leave Forms

Tuition Assistance

UUP Benefit Forms (Dental/Vision/Life/Address/Membership/Student Verification/others)