Forms

 PLEASE CLICK THE LINK BELOW FOR THE APPLICATION YOU WISH TO APPLY FOR

 --PRESCRIPTION DRUG PREMIUM CONTRIBUTION REIMBURSEMENT - STATE MEMBERS ONLY

Use this form if  you are an active or retired member of Local 1070, and you were enrolled in the New York State Health Insurance Program for the calendar year 2017.   Submission of this application requires your payroll stub, "Advice Date, 12/27/17."   Please mail the application to:  District Council 37, Health & Security Plan, 125 Barclay Street, FL BSMT, New York, New York 10277-1279, Attention:  Accounting, 3rd Floor.   Any questions regarding the status of a submitted claim can be directed to 212-815-1290.

PDF icondrug_premium_reimbursement_-_2017.pdf

--PRESCRIPTION DRUG CO-PAYMENT REIMBURSEMENT CLAIM - STATE MEMBERS ONLY

Use this form if you are an active or retired member of Local 1070.  Please mail application to:  District Council 37, Health & Security Plan, 125 Barclay Street, FL BSMT, New York, New York 10277-1279, Attention, Drug & Optical.  Any questions about the status of a submitted claim can be directed to 212-815-1608.

PDF icondrug_copay_reimbursement_2017.pdf

--APPLICATION FOR SICK LEAVE BANK

                                      (UNIFIED COURT SYSTEM EMPLOYEES ONLY)

To apply for the sick leave bank, you and your doctor must fill-out the attached form completely.  You may either fax or mail the completed form to the fax number or to the address on the form, NOT the Local 1070 office.  The date that the Labor Relations Office receives the form will be considered the date of submission.

PDF icon1070_sick_bank_application_form_10.25.12_1.pdf

FMLA

     -- GUIDELINES

PDF iconfmlaguidelines_1.pdfPDF icon<br>

     -- FORMS

PDF iconucs_48_with_instructions.pdf

PDF iconhttps://www.dol.gov/whd/fmla/forms.htm

--DISABILITY CLAIM FORM - ALL MEMBERS

Please read and follow all of the instructions carefully or your claim may be delayed or returned.  The physicians statement must be entirely completed and ONLY by a licensed medical doctor

PDF icon short_term_disability_form.pdf

--WORKER'S COMPENSATION INFORMATION

PDF iconworkers_compensation.pdf

--BENEFICIARY FORM - ALL MEMBERS

This completed and notarized Change of Beneficiary form will designate who will receive your Death Benefit.   It is very important to keep this form updated.

PDF iconbeneficiaryform_3.pdf

--TUITION REIMBURSEMENT – ACTIVE MEMBERS

To apply for reimbursement, a member must submit an original application form for the term.  At the end of the term, the member must submit a completed application form along with a grade report or completion of course documentation.  This information must be received no later than 120 days after the last day of class.

If you have taken a prep course, for instance, for an upcoming exam, you must pay up front and submit a completed application form, a letter of completion or certificate and a copy of your receipt to get the reimbursement

PDF icontuition_reimbursement_form.pdf

--DIRECT OPTICAL REIMBURSEMENT FORM – STATE MEMBERS

Please read carefully.  This claim has to be made within 90 days from the date of service.  (This is the 2018 form.)  The optical benefit is only available for one instance of service in each 12-month period.

directopticalreimbursement_3.pdf

-- DIRECT OPTICAL REIMBURSEMENT FORM – city MEMBERS

Please read the attached form carefully.  Claims filed later than 30 days from the date of service will be declared ineligible.

PDF iconcity_optical_reimbursement.pdf

--ENROLLMENT FORM - ALL MEMBERS

In order for the DC 37 Health and Security Plan to provide Welfare Fund Benefits to you and your dependents, you must complete the attached enrollment form.

PDF iconh_s_enrollment_form.pd

--EMPLOYEES PAYROLL DISCREPANCY FORM – STATE MEMBERS

This form allow, employees to report any discrepancy in their pay.

PDF iconpayroll_discrepancy_form.pdf

--RECLASSIFICATION FORM - STATE MEMBERS

PDF iconAccording to the Rules of the Chief Judge; Part 25: Career Service, Statute 25.5-Classification and Allocation Section (d) Review of classification and allocation.  Any nonjudicial employee, employee organization or court administrator directly concerned in any classification or allocation of a position in the Unified Court System may seek review of that classification or allocation by submitting a request, in writing, to the director of personnel of the Unified Court System setting forth the basis of the change requested, together with any supporting papers.  The director of personnel shall conduct such inquiry as is necessary and recommend to the Chief administrator any required adjustments in the classification or allocation.  The Chief Administrator shall determine the request for review and shall notify </span>

PDF iconreclassification.pdf

--EXPOSURE FORM – ALL MEMBERS

This form allows all members to document any incident of harmful exposure.  Please fill out this form in its entirety.  Once completed, keep a copy for your records.

PDF iconexposure_ltr.pdf

--AFFIDAVIT FOR STOLEN OR LOST DRUG I.D. CARD - CITY MEMBERS

To replace a lost or stolen drug ID card, please print-out the form and provide the requested information.  Return the form to DC 37 Health and Security, 125 Barclay Street, New York, New York 10007.

PDF iconstolen_or_lost_drug_card.pdf

--VOLUNTARY REASSIGNMENT – STATE MEMBERS

Pursuant to Section 23.1(a) of the 2016-2019 Agreement between the State of New York Unified Court System and DC-37, Local 1070 competitive class title members may submit a Voluntary Request for Reassignment (transfer) form to the Office of Court Administration.

The term “reassignment” (transfer) means a change without further examination, of a permanent employee, from his or her present permanent title, position in the same grade and salary under a different administrative authority.

This form must be filled out completely and mailed to Albany, New York.

PDF iconnew_voluntary_reassignment_request_form_4.pdf

--VOLUNTARY REQUEST FOR CHANGE IN ASSIGNMENT - STATE MEMBERS ONLY

Pursuant to Section 23.2(a) of the 2011-2016 Agreement between the State of New York Unified Court System and DC 37, Local 1070,  the Voluntary Change in Assignment  form is now available.  

PDF iconvoluntary_request_for_change_in_assignment.pdf

--DENTAL CLAIM FORM - ALL MEMBERS

Please complete the form in its entirety.  If you have any questions, please call Maureen Castagnetti at 212-815-1335.

PDF icondental_claim_form.pdf

--CHANGE OF STATUS FORM – All Members

This form is for both our City and State members.  If you enroll (or change) any dependents, spouse or domestic partner.  It is Mandatory that you attach all required documents.

PDF iconchangeofstatus_form.pdf

--LOST OPTICAL VOUCHER - ALL MEMBERS

To replace an optical voucher,  this form must be completed, notarized and returned to DC 37 Health and Security Department, 125 Barclay Street, 8th Floor, New York, New York 10007

PDF iconlost_optical_voucher.pdf

--TIERS 3, 4, 5 and 6 LOAN APPLICATION – CITY MEMBERS

See Pages 4 and 5 for instruction on completing this form.  Albany will not accept fax applications.  You must answer all questions in ink and the application must be signed and notarized, if not, it will be rejected

PDF icontiers_3_4_5_6_loan_application.pdf

eligible list Change of Location Preference Form

PDF iconlocpref-eligiblelist_1.pdf

MUNICIPAL EMPLOYEES HOUSING PROGRAM

PDF icon housingapp.pdf