Empire Plan Insurance
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- Empire Enrollment/Change Form
- Empire Plan Claim Forms (all coverages)†
- Request for Empire Plan replacement card
Effective January 1, 2018 we will be switching to a new claims administrator for our dental and vision claims. There are no changes in benefits, only a new claims administrator The Preferred Group.
- To file claims for Flexible Spending plan, apply for direct deposit of reimbursement and to apply for a benefit card, login to the SUNY Orange Portal, employee tab.
- Remission Form (credit classes for dependents & spouse)
- Waiver Form (noncredit classes for dependent/spouse; credit classes for self)
- Dependency Form (must be completed every calendar year for each dependent)
- CSEA Tuition Reimbursement Form (credit classes for civil service employees)
Employee Change Form:
- Employee Information & Change Form (name, address, phone or emergency contact changes)
- Life Changes Checklist
If you have any problems accessing these forms, please contact Human Resources.