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CSEA MEMBERSHIP APPLICATION
CSEA & TOH FORMS
CSEA Retiree Application
Family Medical Leave Act (FMLA) – For Employee
Family Medical Leave Act (FMLA) – For Family Member
Vacation In-Lieu of Sick Form
Direct Deposit Form
Direct Deposit Form (credit union)
Catastrophic Leave Application (initial)
Catastrophic Leave Application (extension)
Catastrophic Leave Donation Form
AFLAC Withdrawal Form
United Way Withdrawal
Legal Assistance Program Payroll Deduction Form
NYS RETIREMENT & LOANS
Application for Service Retirement – rs6037
Electronic Funds Transfer Direct Deposit Enrollment Application – rs6370
Retirement Option Election Form For Tier 3, 4, 5 and 6 ERS Members – rs6399
MEDICAL
EMPIRE PLAN Participating Provider Database
EMPIRE PLAN Pharmacy Reimbursement Claim Form
EMPIRE PLAN Health Insurance Claim Form
AFLAC Initial Disability Claim Form
DENTAL
Dental Providers
HEALTHPLEX Dental Claim Form – F-2203
OPTICAL
GVS Discount & Providers List (General Vision Screening)
Vision Screening Discount & Providers List
HEALTHPLEX Vision Claim Form – F2014.1
PEARL INSURANCE
Pearl Insurance Disability Income Claim Form
Pearl Insurance EZ-Pay
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HOME
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Expand
Join CSEA!
CSEA ID# Lookup
Member Discounts
Medical/Dental/Vision
Forms & Downloads
Scholarship Program
Defensive Driver Course
Civil Service Testing
EAP (Employee Assistance)
NEWS
EVENTS
CONTACT US