NYCERS / Form for Deduction from Pension for Dental Coverage Please enable JavaScript in your browser to complete this form.Pensioner Name *FirstLastPension # *Email *Phone *SSN *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeI hereby authorize NYCERS to deduct from my pension check on a regular monthly basis an amount sufficient to pay the premiums for my insurance policy and or any renewal of such policy, and to remit such amounts each month to the TWU Retirees’ Association.I hereby authorize NYCERS to change the amount of the deduction in the event an adverse underwriting decision is made or to reflect any changes in coverage I may request.Dental *$18 (HMO –MEMBER)$45 (PPO – MEMBER)$42 (HMO – MEMBER + 1)$80 (PPO – MEMBER + 1)$50 (HMO – MEMBER 2+)$110 (PPO – MEMBER 2+) Phone Pension $ Vision (Optional):$16 (MEMBER)$30 (MEMBER +1)$45 (MEMBER + 2 or more)Other (Optional) with $:(life insurance, legal, other)Total $ Amount (in USD) *Signature * Clear Signature By signing this form, you agree to remain in the plan and have deductions taken from your pension check for a minimum of 12 monthsSubmit
