PLEASE CLICK THE LINK BELOW FOR THE APPLICATION YOU WISH TO APPLY FOR:
STATE MEMBERS ONLY
Use this form if you are a member of Local 1070 (active or retired), and you were enrolled in the New York State Health Insurance Program for the calendar year 2023. Submission of this application requires your December payroll stub. Please mail the application to: District Council 37, Health & Security Plan, 55 Water Street New York, N.Y. 10041, Attention: Accounting or fax 646-496-9114. Any questions regarding the status of a submitted claim can be directed to 212-815-1290.
Active Members
medical_insurance_reimbursement_form.pdf
Retirees
l.1070_retirees-_letter_and_form_drug_premium_contribution_reimbursement_2022_final.pdf
--PRESCRIPTION DRUG CO-PAYMENT REIMBURSEMENT --
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, 55 Water Street New York, N.Y. 10041, Attention: Accounting or fax 646-496-9114, Attention, Drug & Optical. Any questions about the status of a submitted claim can be directed to 212-815-1608. <br>
local_1070_drug_copay_reimbursement_letter_and_application_2022_final.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.
***Please note that you must fill-out:
1) an Application for Leave form, and
2) return to work form, as well as the sick leave
BANK FORM
when you are requesting Sick Leave Bank time***
sick_leave_application_-_august_2019_1.pdf
--APPLICATION FOR LEAVE AND INSTRUCTIONS--
(UNIFIED COURT SYSTEM EMPLOYEES ONLY)
application_for_leave_with_instructions.pdf
-- Return to Work form --
return_to_work_medical_provider.pdf
FMLA
-- GUIDELINES
fmlaguidelines_1.pdf <br>
-- FORMS
https://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
short_term_disability_form.pdf
--WORKER'S COMPENSATION INFORMATION--
--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.
OCA's DISCRIMINATION CLAIM POLICY AND PROCEDURES WITH CLAIM FORM
--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
tuition_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.
city_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.
--EMPLOYEES PAYROLL DISCREPANCY FORM
STATE MEMBERS
This form allow, employees to report any discrepancy in their pay.
--RECLASSIFICATION FORM -
STATE MEMBERS
--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.
--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.
--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.
reassignment_form_all_titles.pdfreassignment_form_all_titles.pdfreassignment_form_all_titles.pdfreassignment_form_all_titles.pdfreassignment_form_all_titles.pdfreassignment_form_all_titles.pdfreassignment_form_all_titles.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.
voluntary_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.
--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.
--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
--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
tiers_3_4_5_6_loan_application.pdf