NYCERS Transport Workers Union Retirees’ Association Voluntary Dental/Vision Insurance Pension Deduction Authorization and Waiver Please enable JavaScript in your browser to complete this form.Pensioner Name *FirstLastEmail * Phone Address (Optional) Phone *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePass # *I 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)$42 (HMO MEMBER + 1)$45 (PPO –MEMBER)$50 (HMO – MEMBER 2+)$80 (PPO –MEMBER +1)$110 (PPO – MEMBER 2+)Vision (Optional):$16 (MEMBER)$30 (MEMBER +1)$45 (MEMBER + 2 or more)Other (Optional) with $:(life insurance, legal, other)Submit
