Health & Security Forms, Registration and Change of Status

Health and Security Plan Benefits: Various benefit packages available to actively working members and retirees. All benefit informations and claim forms are available through the Health and Security Plan's Inquiry Unit.

• Health and Security Plan's Inquiry Unit:  (212) 815-1234.
• If you have a teletypewriter, call (212) 815-1266 for forms and information.
• The Retiree toll-free number is 1-877-323-7738 for those outside the NY-NJ-CT area.

Please click here for more information.

DC 37 HEALTH & SECURITY PLAN FORMS

• - H&S Enrollment Form
• - Change of Status Form
• - Death Benefit Application Form
• - Beneficiary Form
• - Death Benefit Affidavit Form
• - ADA Dental Form
• - Dental Providers
• - Optical Reimbursement Form
• - Optical Providers
• - Annuity Benefit Application Form
• - Annuity Benefit Beneficiary Designation Application Form
• - Annuity Benefit Rollover Application Form
• - Disability Claim Form
• - COBRA

All forms above are available in PDF format. Each form includes instructions.