Online Benefits Orientation: Checklist

When you have finished the online orientation and made your benefit elections, please complete this checklist to acknowledge you have reviewed the benefits information and completed necessary forms. Print, sign, and bring this checklist along with all other forms to the Employee Benefits Office, Cleveland Hall 410, within 30 business days of your appointment. Contact the Employee Benefits Office if you have any questions at 878-4821.

Name:
Title:
Telephone:
Campus Appointment Date:

Health Insurance:
	I do not wish to enroll in health insurance. Proceed to Dental and Vision Care. Opt Out Program: complete PS-409 Form AND PS-404 Form Empire Plan Community Blue (HMO) Independent Health (HMO) Health Insurance Enrollment Form (PS-404) (required if enrolling or electing to participate in the Opt-Out Program)
Coverage Type:
	individual family
If electing family coverage or electing to participate in the Opt-Out Program (for the family coverage incentive), attach a copy of the following documentation:
	marriage certificate birth certificate(s) for all dependents Social Security card(s) for all dependents

Dental and Vision Care:
	Completed CSEA Enrollment Form

Retirement Plans:
	I wish to join the NYS Employee's Retirement System (ERS).
		Completed NYS Employees' Retirement System Application
	I am presently a member of NYS Teacher's (TRS) or the NYS Employee's Retirement System (ERS).
	Membership Date: Number: Tier:
	(enter format: mm/dd/yyyy)

	I do not wish to join a retirement plan at this time (optional only for those with part-time appointments).

Tax Deferred Annuities and College Savings Program:
	I have reviewed the information

Flex Spending Accounts (Dependent Care Advantage and Health Care Spending accounts):
	I have reviewed the information

Vacation and Sick Leave:
	I have reviewed the information

Insurances:
	Long-Term Care Insurance (optional)

Education:
	I have reviewed the information

Payroll Forms and Emergency Contact Information:
	NYS IT-2104 (state)
	W-4 (federal)
	Payroll Calendar
	Direct Deposit (optional)
	Emergency Contact Information Form
	Credit Union (optional)
	U.S. Savings Bonds (optional)

Campus Information and Policies:
	Campus Map and Directions
	Workplace Violence Prevention Training
	Safety Awareness
	Holidays
	Employee Assistance Program
	Child Care Center
	Policy on Alcohol and Drug Use in the Workplace
	General Policy Against Discrimination and Harassment

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Telephone: (716) 878-4822, FAX: (716) 878-3068
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