Forms

• Active Beneficiary Enrollment Card

  • Click here to download a preview sample of the Active Beneficiary Enrollment Card 

• Anesthesia Claim Form - Surgical

• Anesthesia Claim From - Maternity

• Change of Address Form

• Compensation Accrual Fund

• Domestic Partner Update

• GVS Optical Reimbursement Form

• Health Benefits Application

• NYC Offered Health Plans

Proby Enrollment

• Probie Class Intro

• Active Beneficiary Enrollment Card 

  • Click Here to Submit Active Beneficiary Enrollment Card via DocuSign

• SBF Conditional Benefits (Only applicable if original enrollment is incomplete)

• Beneficiary Enrollment Card (Retirees)

  • Click here to download a preview sample of the Retired Beneficiary Enrollment Card

• Change of Address Form

• Domestic Partner Update

• GVS Optical Reimbursement Form

• NYC Fire Pension Fund Change of Address Form

• NYC Fire Pension Fund Check Affidavit

• NYC Fire Pension Fund Electronic Fund Transfer Form

• NYC Fire Pension Fund - Life Insurance Fund Beneficiary Form

• NYC Fire Pension Fund W-4P Form

• NYC Offered Health Plans

• Medicare Part B Reimbursement Application

  • For more information regarding Medicare Part B, please visit: https://www1.nyc.gov/site/olr/health/retiree/health-retiree-medb-irmaa.page

• Retired Firefighter Security Benefit Fund (RFSBF) Summary of Benefits

• Senior Care Court Decision August 2024

• Senior Care Copay Notice 2025

• IRMAA Reimbursement Form

  • For more information on IRMAA Reimbursements, visit: https://www1.nyc.gov/site/olr/health/retiree/health-retiree-medb-irmaa.page

  NYC OLR Heath Benefits Program

• NYC Health Plans

• October 2024 Rate Change Notice 

• October 2024 Rate Chart - Employees Only **

• October 2024 Rate Chart - Retirees Only **

• October 2024 COBRA Package

• October 2024 Rate Chart for Young Adult Option (Dependents under 29)

  Surgical Assistance Fund

• Surgical Assistance Fund Application

• Surgical Assistance Fund Fee Rates

• Surgical Assistance Fund Summary of Benefits 

• FDNY Line-of-Duty (LODI) Prescription Benefit Plan

• FDNY World Trade Center Health Program - WTC Prescription Plan Update Fact Sheet

• What's In Your Wallet? Prescription Card Fact Sheet

• MetLife Dental Benefits 

• MetLife Video for UFA Members 

• MetLife Dental Benefits - Effective Jan 2024 

• MetLife & UFA

• MetLife December 2023 Update 

• MetLife Preferred Dentist Program (PDP)

  • Those currently enrolled in the UFA Dental plan will be in the MetLife PDP plan effective 1/1/24.

  • PDP FAQS 

  • Out of Network Claim Form

• MetLife Managed Care Plan (HMO)

  • Those currently enrolled in Dentcare will be in the MetLife HMO/Managed Care Plan effective 1/1/24.

  • HMO/Managed Care FAQs 

• Change of Address Checklist

• Divorce Checklist

• Domestic Partnership Checklist

• New Baby Checklist (Active and Retired)

• Newly Wed Checklist (Active and Retired)

• Retirement Checklist

• December 2024 NYC Fire Pension Fund Mailing: Updating Beneficiaries

  • Letter to Service Retirees

  • Letter to All Other Retirees 

  • Life Insurance Beneficiary Form

  • VSF Beneficiary Form 

  • Final Pension Payment Beneficiary Form

• Change of Address Form

• Check Affidavit

• Electronic Fund Transfer Form

• Pension Fund Manual

• Retirement Checklist

• Telephone Directory

• Tier II Vesting Info

• Tier III Vesting Info

• Vested Application

• Virtual Retirement Seminar Schedule 2025

• W-4P Form