Benefit Forms
The forms below are available in printable format.
Contract College Health and Dental Insurance
- Contract College PS-404 Form (PDF)
- Contract College PS-404 Instructions (PDF)
- Contract College PS-425 Form (PDF) to Enroll a Domestic Partner in NYSHIP / Dependent Tax Affidavit / Termination of Domestic Partnership
- Contract College PS-457 (PDF) NYSHIP Statement of Dependence (PDF)
- Deferred Health Insurance Coverage (PDF)
- ValueOptions Claim Form: Contract College (PDF)
- NYSHIP COBRA Request Form (PDF)
- Empire Plan/United Health Care Claim Form (PDF)
- Optumhealth Claim Form (PDF)
- GHI Claim Form (PDF)
- The Empire Plan Prescription Drug through Medco Mail Service Order Form (PDF)
- The Empire Plan Prescription Drug through
Medco Reimbursement Claim Form (PDF)
Additional benefits forms may be obtained by contacting Benefit Services, 255-3936, or e-mail benefits@cornell.edu.
Form more information on Cornell's benefit programs, refer to our benefits pages.