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Forms
The following is a list of important forms, which are available for download and print. The documents are all in PDF format, and you will need Acrobat Reader to view them. If you do not have Acrobat Reader, please click here to download and install the plug-in before downloading the form.
GENERAL
- Change of Address or Phone Number Form: Use this form, or make changes online, to inform the Funds of changes in address or contact information.
ENROLLMENT
- Enrollment Form for New Members: Use this form to send your enrollment and information to the 32BJ Benefit Funds. You can also enroll your family at the same time by carefully reading and completing section 3 (click on “Dependent Documentation Table” below for more information on what documents we need to enroll your eligible dependents).
- Enroll or Change Dependent Status Form: Use this form to add new dependents or change the status of any of your previously enrolled dependents.
- Definition of Eligible Dependents: This form is used to identify which dependents are eligible for coverage.
- Dependent Documentation Table: This form is used to identify which documents are required for dependents to be covered under your benefit plan.
- Student Re-Certification Form: This form is used to continue benefit coverage for your over 19 year old dependent full-time student.
- Domestic Partner Application Cover Letter/
La carta de explicación de la solicitud para la pareja conviviente
Domestic Partner Questions & Answers/
Preguntas y respuestas sobre la pareja conviviente
Domestic Partner Affidavit of Financial Interdependence/ Declaración jurada de
interdependencia económica de la pareja conviviente
MEDICAL
- Empire’s Claim Form: Complete this form for reimbursement from Empire for all out-of-network treatment/care.
LIFE INSURANCE
- Metropolitan Life Insurance Co. Beneficiary Designation Form
VISION
- Vision Claim Form: This form is used for reimbursement if you choose to us an Out-of-Network provider.
PENSION/SRSP
- $1,000 Death Benefit for Pensioners: The Health Fund provides a death benefit of $1,000 if the deceased was collecting a monthly pension from the Building Service 32BJ Pension Fund.
- Beneficiary Form—Pensioners may use this form to select a beneficiary for the $1,000 Death Benefit. (Pensioners must sign, date, and return the form to Building Service 32BJ Pension Fund 101 Avenue of the Americas, New York, NY 10013)
- Death Benefit Claim Form—This form is to be filled out by the named beneficiary to claim the $1,000 death benefit. If there is no named beneficiary, spouse may claim benefit by filling out this form.
- Death Benefit Affidavit Form—This form is completed by children, parents or the administrator of the estate for the deceased if there are no named or living beneficiaries and the Pensioner was single at the time of death.
- Small Estate Affidavit Form—If no one is eligible to claim the benefit and there is no Administrator for the Estate, complete this form.
- Direct Deposit Pension Form: Use this form to enroll for direct deposit of your pension benefits.
- Pension/SRSP Release of Information (ROI) form: Members use this form when they want a third party to receive information about the member’s Pension/SRSP benefits verbally.
- SRSP Deferral Form: Members use this form to elect the amount of pre-tax money they want to contribute to their 401(k) account.
HEALTH
- Health Release of Information (ROI) form: Members use this form when they want a third party to receive information about the member’s health benefits verbally.
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