Preferred Group - Dental Claims
NOTE: Only use this form to make a claim when you use a non-participating dentist OR when you initially go to a participating dentist. This form pertains to all NTA, clerical SRP, administrator bargaining units and retirees that have this coverage.
Davis Vision - Vision Claims
NOTE: Only use this form to make a claim when you use a non-participating vision provider. Active SRP's should not use this form, but rather the vision claim form for National Vision Administrators. Active SRP's should not use this form.
ShelterPoint Life & National Vision Administrators (vision plan rider on XMM)
1. For active teachers and teaching assistants, the policy number is XGNY 91194 and Employer is Nanuet Teachers Association Benefit Fund.
2. For retired teachers and teaching assistants, the policy number is XGNY 1194 and Employer is Nanuet Teachers Association Benefit Fund.
3. For administrators and SRP's the policy number is XGNY 1133.
ShelterPoint In-Hospital Claim Form (Primary insured benefit only - $50 per night in hospital stay)
Preferred Group - FLEX 125 Spending Account
NOTE: The FLEX Spending forms are here for your convenience. IT CAN ONLY BE USED IF YOU HAVE SIGNED UP FOR THIS PLAN THROUGH DISTRICT PAYROLL. Please contact The Preferred Group or payroll if you have any questions.
Preferred Group - AFLAC
United Health Care (physician portion of NYSHIP)
NOTE: Completed claim forms along with the doctor's bill may also be faxed to either of these three numbers: 845-336-7989; 845-336-7747; 845-336-7716
Dependent Student Certification
NOTE: This form must be completed by the college registar to validate full time enrollment and submitted to Preferred Group Plans. Fall semester verification covers 8/1 - 3/31. Spring semester verification covers 1/1 - 8/31.
Three Month Extension of Benefits for College Graduate
NOTE: An unmarried dependent student, nineteen years of age or older, but under twenty-five, who graduates from an accredited secondary or preparatory school, college or other educational institution, may continue coverage for up to three months following the end of the month in which course requirements for graduation are completed. There is no extra cost for the extended coverage period but family coverage must be continued for three months. After the three month extension, the graduating dependent will be eligible for the full thirty-six months of COBRA coverage. You can find additional information by clicking here.