Forms for Members

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Beneficiary Form for Pension Benefits

All Funds

Pension

Benefit Fund Appeal Representation Authorization Form

All Funds

Healthcare

Change of Address – Active Members

All Funds

Healthcare

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Change of Address – Retirees

All Funds

Pension

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Coordinated Care Program Opt-Out Form

All Funds

Healthcare

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Coordination of Benefits Form for Spouse Coverage

National Benefit Fund

Healthcare

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Coordination of Benefits Form for Spouse Coverage

Greater New York

Healthcare

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Coordination of Benefits Form for Young Adult Coverage

All Funds

Healthcare

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Parent and Guardian Affidavit

All Funds

Pension

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Pension Payment Election Form

All Funds

Pension

Provider Recruitment Form

All Funds

Healthcare

Request for Pension Estimate

All Funds

Pension

co-pay copay payments online bill invoice retirees pensioner retirement auto deposit autodeposit automatic monthly check

Statement Claim for Hospital Indemnity Benefit

All Funds

Healthcare

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Supplemental Medical Information OB-GYN

All Funds

Healthcare

Supplemental Medical Information Physical Medicine and Rehabilitation

All Funds

Healthcare

Notice of Total or Partial Rejection of Claims for Disability Benefits

National Benefit Fund

Healthcare

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Accidental or Occupational Disease Compensation Report

National Benefit Fund

Healthcare

billing bills claims cob coordination coverage balance eob explanation explain mail invoice owe charge money copay deductable coinsurance premium

Aetna MAPD Medical Waiver Request Form – for Retiree, Spouse and Physician

National Benefit Fund

Healthcare/Pension

Affidavit for Unlocatable Spouse

National Benefit Fund

Pension

husbands wifes wives spouses children kids babys infants sons daughters dependants date of birth dob birthday institution hospital nursing home agency health center

Application for Disability Pension

National Benefit Fund

Pension

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Application for Normal or Early Pension

National Benefit Fund

Pension

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Application for Surviving Spouse Pension

National Benefit Fund

Pension

co-pay copay payments online bill invoice

Disability Claim – Direct Deposit Form

National Benefit Fund

Healthcare

Notice and Proof of Claim for Disability Benefits Form

National Benefit Fund

Healthcare

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Disability Supplemental Medical Information (SMI) General Form

National Benefit Fund

Healthcare

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Enrollment Change Form

National Benefit Fund

Healthcare

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Enrollment Form – Pension Fund Only

National Benefit Fund

Pension

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Enrollment Form (Benefits and Pension)

National Benefit Fund

Healthcare

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Life Insurance Benefit Claimant’s Statement

National Benefit Fund

Healthcare

CVS Caremark Mail Order Prescription Form

National Benefit Fund

Healthcare

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Member Reimbursement Medical Claim Form

All Funds

Healthcare

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Paid Family Leave Form

National Benefit Fund

Healthcare

pfl leaves time off husbands wifes wives spouses children kids babys infants sons daughters dependants

Express Scripts: Prescription Reimbursement – Coordination of Benefits Claim Form

Only for drugs purchased on or before 6/30/2024. For newer purchases, see the related CVS Caremark form.

All Funds

Healthcare

Prescription Request for Authorization

National Benefit Fund

Healthcare

Service/Equipment Request for Authorization

National Benefit Fund

Healthcare

State of New York Workers’ Compensation – Attending Doctor’s Report Form

National Benefit Fund

Healthcare

co-pay copay payments online bill invoice

State of New York Workers’ Compensation – Claimant’s Request for Further Action

National Benefit Fund

Healthcare

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State of New York Workers’ Compensation – Employees Claim for Compensation

National Benefit Fund

Healthcare

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State of New York Workers’ Compensation – Medical Proof of Change in Condition

National Benefit Fund

Healthcare

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Statement of Claim for ESRD Medicare Part B Active Members

National Benefit Fund

Healthcare/Pension

billing bills claims cob coordination coverage balance eob explanation explain mail invoice owe charge money copay deductable coinsurance premium

Statement of Claim for Medicare Part B Premium Reimbursement

National Benefit Fund

Healthcare/Pension

billing bills claims cob coordination coverage balance eob explanation explain mail invoice owe charge money copay deductable coinsurance premium

Statement of Claim for Medicare Part D Reimbursement Form

National Benefit Fund

Healthcare/Pension

billing bills claims cob coordination coverage balance eob explanation explain mail invoice owe charge money copay deductable coinsurance premium

Aetna MAPD Medical Waiver Request Form – for Retiree, Spouse and Physician

Greater New York

Healthcare/Pension

Affidavit for Unlocatable Spouse

Greater New York

Pension

husbands wifes wives spouses children kids babys infants sons daughters dependants

Application for Normal, Early or Disability Pension

Greater New York

Pension

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Application for Surviving Spouse Pension

Greater New York

Pension

Enrollment Change Form

Greater New York

Healthcare

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Enrollment Form (Benefits and Pension)

Greater New York

Healthcare

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GHI Dental Enrollment Form

Greater New York

Healthcare

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Life Insurance Benefit Claimant’s Statement

Greater New York

Healthcare

Spouse Coverage and Payroll Deduction Authorization Form

Greater New York

Healthcare

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Statement of Claim for ESRD Medicare Part B Active Members

Greater New York

Healthcare/Pension

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Statement of Claim for Medicare Part D Reimbursement Form

Greater New York

Healthcare/Pension

billing bills claims cob coordination coverage balance eob explanation explain mail invoice owe charge money copay deductable coinsurance premium

Enrollment Change Form

Greater New York for NJ

Healthcare

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Enrollment Form (Benefits and Pension)

Greater New York for NJ

Healthcare

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Affidavit for Unlocatable Spouse

Home Care

Pension

husbands wifes wives spouses children kids babys infants sons daughters dependants

Application for 36-month or 60-month Guarantee Pension

Home Care

Pension

Application for Normal, Early or Disability Pension

Home Care

Pension

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Beneficiary Form for Single Working Members

Home Care

Pension

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Enrollment and Plan Election Form

Home Care

Healthcare

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Dependent Child Enrollment Form

Home Care

Healthcare

Life Insurance Beneficiary Form

Home Care

Healthcare

Life Insurance Benefit Claimant’s Statement

Home Care

Healthcare

Enrollment Form

Licensed Practical Nurses Welfare Fund

Healthcare

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Application for Normal, Early or Disability Pension

Former 144 Hospital Division

Pension

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Training and Employment Funds

Providing Training, Education, and Employment-related services to eligible 1199SEIU members.

Training and Employment

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Child Care Funds

Access high quality, affordable programs and services for children from birth to age 17.

Child Care Funds

Enrollment and Plan Election Form for CBO

Home Care

Healthcare

CVS Caremark: Prescription Drug Reimbursement Form (Direct Claim Form)

All Funds