2013 Annual Open Enrollment/Change Forms
Note: Only forms are accessible here. To download both the forms and the Summary of Benefits Booklet that was mailed to you, please sign on to the Self-Service website and click on Annual Open Enrollment Information & Forms in the News and Updates section.

ACTIVE EMLOYEES

HR-BEN-060K 2013 NYSHIP Annual Open Enrollment/Change Form
MTA Headquarters (BSC, CC, IG, Police), Long Island Rail Road, Metro-North, NYC Transit NYSHIP Groups

HR-BEN-060L 2013 NYSHIP HMO Annual Open Enrollment Change Form
MTA Headquarters (BSC, CC, IG, Police), Long Island Rail Road, Metro-North, NYC Transit NYSHIP Groups

HR-BEN-366A 2013 2013 ANNUAL OPEN ENROLLMENT/CHANGE FORM
Active NY City Group Employees

HR-BEN-367A 2013 ANNUAL OPEN ENROLLMENT/CHANGE DENTAL FORM
Employees under NYSHIP Benefits (except SSSA, TSO Operating and MS II)

HR-BEN-368A 2013 ANNUAL ENROLLMENT/CHANGE FORM
Subway Surface Supervisors Association (SSSA), Non Rep Operating Supervisors (MS II), TWU Local 106 Transit Supervisors Organization (TSO) Operating and Queens Supervisory, Coin Retriever Employees

HR-BEN-369A 2013 ANNUAL OPEN ENROLLMENT FORM
Active ATU L726/SSSA/TSO/Special Inspectors with ATU L726 Benefits

HR-BEN-370A 2013 ANNUAL OPEN ENROLLMENT/CHANGE FORM
Active ATU L1056 Employees/SSSA/TSO Employees with ATU L1056 Benefits

HR-BEN-371A 2013 ANNUAL OPEN ENROLLMENT/CHANGE FORM
Active MTA BUS Employees (Except Spring Creek)

HR-BEN-372A 2013 Annual Open Enrollment/Change Form
Active TWU Local 100, SSSA/TSO/Special Inspectors/TCU & ATDA Employees with TWU Local 100 Benefits
Active SIRTOA United Transportation Union Local 1440 with TWU Local 100 Benefits

HR-BEN-374A 2013 ANNUAL OPEN ENROLLMENT FORM
Active MTA BUS Employees (Spring Creek)

HR-BEN-390 2013 ANNUAL ENROLLMENT/CHANGE FORM
Active Transit Supervisory Organization Local 106 Career & Salary Employees


RETIREES

HR-BEN-366R 2013 ANNUAL OPEN ENROLLMENT/CHANGE FORM
Retired NYCT New York City Group

HR-BEN-367R 2013 ANNUAL OPEN ENROLLMENT/CHANGE FORM
Retired NYCT Under NYSHIP Benefits (Except SSSA, TSO Operating, and MS II)

HR-BEN-368R 2013 ANNUAL OPEN ENROLLMENT/CHANGE FORM
Retired NYCT Subway Surface Supervisors Association (SSSA), Non-Rep Operating Supervisors (MS II), TWU Local 106 Transit Supervisors Organization (TSO) Operating and Queens Supervisory, Coin Retrievers

HR-BEN-369R 2013 ANNUAL OPEN ENROLLMENT/CHANGE FORM
Retired NYCT ATU Local 726, SSSA/TSO Operating/Special Inspectors with ATU Local 726 Benefits

HR-BEN-370R 2013 ANNUAL OPEN ENROLLMENT/CHANGE FORM
Retired NYCT ATU Local 1056, SSSA/TSO Operating/Special Inspectors with ATU Local 1056 Benefits

371R 2013 ANNUAL OPEN ENROLLMENT/CHANGE FORM
Retired MTA Bus

HR-BEN-372R 2013 ANNUAL OPEN ENROLLMENT/CHANGE FORM
Retired NYCT TWU Local 100, SSSA/TSO Operating/Special Inspectors/TCU/ATDA with TWU Local 100 Benefits

HR-BEN-390R 2013 ANNUAL OPEN ENROLLMENT/CHANGE FORM
Retired NYCT Supervisory Organization Local 106 Career & Salary