Complete this form if you have changed your name or address. If you change your name due to marriage, please attach a copy of your marriage license.

Out of Network vision provider form for reimbursement

Complete this form to claim dental benefits

Complete this form, each semester, for your dependent post-secondary student.

Have your orthodontist complete this form before any treatment has begun.

Have your orthodontist complete this form once banding is complete.

Board of Trustees of the Newburgh Teachers’ Association Benefit Trust Fund