When submitting applications for Enrollment please follow the guidelines below:
This Health and Attestation Application is for all SDP provided health plans. You may need to contact your union for prescription, dental and vision benefits.
Complete all sections in entirety.
Please refer to General Documentation Required section for a list of documents that may need to accompany your completed application. The completed application and documentation, if required, can be faxed in to the Benefits Office at (215) 400-4631 or emailed to firstname.lastname@example.org. Please call (215) 400-4630 to confirm receipt.
- Health and Attestation Application
- Request to Remove Spouse or Dependent
- Personal Choice Out of Network Claim Form
- Exchange Notice
- PFT & Local 634 Members: Vision-100eyewarebenefitKey
- CASA, SPAP and Non-Represented Employees: Vision Rider Program Overview
- Non Participating Provider Reimbursement Form
Prescription Drugs – CASA, SPAP and Non-Represented Employees ONLY:
- Select Drug Plan Overview
- Future Scripts Mail Service Order Form
- Prescription Reimbursement Claim Form
Injectable Prescription Drugs – PFT and Local 634 employees. Select the form corresponding to your prescription. If your prescription is not listed, use the General Direct Ship Request form.
- Viscosupplementation (Hyaluronate Acid Products)
- Xolair (Omalizumab)
- Vivitrol (Naltrexone)
- Stelara (Ustekinumab)
- RSV Synagis Prolia_Xgeva (Denosumab)
- Nucala (Mepolizumab)
- Hydroxyprogesterone Caproate Injection
- General Direct Ship Request Form
- Fasenra (Benralizumab)
- Epi Pen Reimbursement Form
- Botulinum Toxins (Botox, Dysport, Myobloc, Xeomin)
Life Insurance Beneficiary Forms must be received by mail. Faxed or scanned Life Insurance Forms will not be accepted.
- Affidavit of Sole Survivor
- Application for Conversion of Group Term Life Insurance
- Life Insurance Beneficiary Designation Form
- Evidence Of Insurability
Flu Vaccine Reimbursement Form
Flexible Spending Account (FSA)
For all types of accounts ** To be sent directly to AmeriFlex
Commuter or Parking Accounts
403(b) & 457(b)
Wage Continuation (Salary Continuance)
PFT, CASA, Non-Represented, Local 634, District 1201/32 BJ and SPAP employees can only apply for Wage Continuation coverage within 30 days of date of hire or during the annual Open Enrollment period in May. Wage Continuation enrollment and cancellation forms are available May 1 to May 31 on the Open Enrollment page.
Name Change/Demographic Change Request
Employees must contact Payroll, email@example.com or 215-400-4490 to request an address change or a change in tax withholding status.
COBRA /RETIREE Coverage forms