Benefits Forms
Download claim forms for medical, dental, vision care, and prescription services. Print out what you need, fill it out, and send it to the appropriate vendor.
Medical, Vision & Dental
CIGNA Claim Form for Hospital/Medical (PDF)
CPS - Claim Form for In-Network Vision
CPS - Claim Form for Out-of-Network Vision
Retiree Health Program Enrollment/Change Form (PDF)
Caremark – Prescription Reimbursement Claim Form (PDF)
Caremark – Prescription Order Form (PDF)
SilverScript prescription claim form for Medicare retirees (PDF)
Met Life – Dental Claim Form (PDF)
Insurance & Pension
Met Life – Beneficiary Designation Form (PDF)
Met Life – GUL Beneficiary Designation Form (PDF)
Direct Deposit Form for Retired Employees (PDF)
Federal Tax Withholding Form (PDF) Please email your W4 to Con Edison Payroll
New York State Tax Withholding Form (PDF)