Forms
Health Insurance
- Empire Claim Form (PDF)
- Mail the form to:
United Health Care
Insurance Co of NY, PO Box 1600
Kingston, NY 12402-1600
- Mail the form to:
Dental/Vision Insurance
- Dental Claim Form (PDF)
- Dental Claim Form (TXT)
- Dental Claim Form (Back - instructions)(PDF)
- Dental Claim Form (Back - instructions) (TXT)
- Dental/Vision Change Form (PDF)
- Dental/Vision Change Form (TXT)
- Vision Claim Form (PDF)
- Vision Claim Form (TXT)
Section 125
- Section125 Benefit Plan - Health & Dependent Care (Flexible Spending Plan) Enrollment (PDF)
- Section125 Benefit Plan - Health & Dependent Care (Flexible Spending Plan) Enrollment (DOC)
- 125 Health Care Reimbursement (PDF)
- 125 Health Care Reimbursement (DOC)
- 125 Dependent Care Reimbursement (PDF)
- 125 Dependent Care Reimbursement (DOC)
Tuition Remission
- Remission Form (PDF)
- Remission Form (DOC)
- Waiver Form (DOC)
- Waiver Form (PDF)
- Dependency Form (PDF)
- Dependency Form (DOC)
Other:
If you have any problems accessing these forms, please contact Human Resources
All
documents on this page are in the PDF format. You need the Adobe
Reader to be able to view them.
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Human Resources Information:
Phone: (845) 341-4660Fax: (845) 341-4670
Located in Orange Hall,
115 South Street Middletown, NY 10940
occchr@sunyorange.edu