Employee Forms

Medical

• Special Enrollment Form 
• Dependent Handicapped Status Form
• Rx Reimbursement Form
• Medical Reimbursement Form
• Vaccine Reimbursement Form
• Medical Appeal Form
• HIPAA Authorization Form

Dental

• ID Card - How to print your ID 
• How to Switch Plans
• Claim Form

Employee Assistance Program

• Information & Login Instructions 

Human Resources Forms (general)

• Administrator Probation Form
• Employee/Staff Probation Form
• Administrative Evaluation Form
• Exit Interview Questionnaire

Life Insurance

• Beneficiary Form

Onboarding

• Acknowledgment of NYC Safe Sick Leave & Harassment Discrimination Policy
• Change in Personnel Status
• Computer Center Policy
• Conflict of Interest Form
• Employee Reference Form
• Employee Opt-Out of Paid Family Leave Benefits
• Employee Paid Safe and Sick Leave Policy

• Employment Application

  Document

  Employment-Application.pdf (226.24 KB)

• Direct Deposit Form

  Document

  Direct-Deposit-Form.pdf (329.27 KB)
• Employment Eligibility Verification (I-9 Form)
• Employee's Withholding Certificate (W-4)

• Mission Green Book and Acknowledgment

  Document

  Green_Book_2017.pdf (12.86 MB)

• Sterling Background Form

  Document

  Sterling-Background-Form.pdf (1.14 MB)

Vision

• Out-of-network claim form

Tuition

• Tuition Remission Form

TIAA

• MU - Salary Reduction Agreement

  Document

  SALARY-REDUCTION-AGREEMENT.pdf (188.48 KB)

Leaves

• Short Term Disability - DBL Claim Form 
• Family Medical Leave - Request Form
• Family Medical Leave - WH-380 FML Certification for a Family Member 
• New York Paid Family Leave Form
• NYC Safe & Sick Leave Request Form 

24HourFlex

• Dependent Receipt 
• Transaction Dispute 
• Over the Counter Form
• How to submit a receipt
• Letter of Necessity 
• Check Reissue Request 

Academic Credit Union

• Information & Online Enrollment Instructions

• Direct Deposit Form

  Document

  Direct-Deposit-Form.pdf (329.27 KB)

Miscellaneous Benefits

• Liberty Mutual - Discount Home & Auto Insurance 
• TransitChek - Pre-Tax Commuting Assistance 
• Verizon - Discount