Requires Adobe Acrobat Reader
The CSEA Judiciary web site provides several services for its members. Below you will find access to forms, phone numbers, applications, and other related information.
Available Forms & Services
In order to access the forms, you will need the Adobe Acrobat Reader.
The following forms are available in Adobe PDF format for downloading and printing:
- CSEA Employee Benefit Fund Forms:
- Claim Form for Physician Co-Pay and Prescription Drug Co-Pay (combined, up to $325)
- UCS Retiree Claim Form for Physician Co-Pay and Prescription Drug Co-Pay
- Claim Form for Hearing Aid, Maternity
- Dental Claim Form
- UCS Legal Services Plan Voucher
- Vision Care Direct Reimbursement Claim Form – For use with non-participating vision care providers
- EBF Proof of Student Status Form
- Contract Grievance Form
- Non-Contract Grievance Form
- Request for Review of Out-of-Title Work Grievance
- CSEA SLB App – Revised August 2019
- Field Report/Legal Assistance Request
- CSEA Insurance – Address Change Form
- CSEA Name Change Form
- CSEA Court Reporter Minute Agreement Form effective 11-18-08
- CSEA-AFSCME PEOPLE Application
- CSEA Retiree Membership Application
- CSEA Change Form (Address, Name, etc.)
- CSEA Attorney Gun Discharge Program (Updated 2019)
- Court Officer Off Duty Security Form
- Application for Workers Compensation Leave – UCS57
- Workers Comp – Certificate of Attending Physician – UCS58
- Return to Work Forms
- Return to Work Forms – Court Officers
The Empire Plan Information
Use this toll-free number to reach United Healthcare, Empire Blue Cross and Blue Shield, ValueOptions, Express Scripts, and the Empire Plan Nurseline.
The New York State Health Insurance Program (NYSHIP) web site contains information regarding health benefits and links to health insurance providers and forms. To access their web site, click here: NYSHIP Online.
- Empire Plan Health Insurance Form
- View 2008 (and beyond) Empire Plan Changes
- 2013 Empire Plan Preferred Drug List
Corporate Counseling Associates: Work / Life / Assistance Program
24-Hour Helpline – 1-800-833-8707.
“We want you to be successful in your personal and professional lives. We are offering a free and confidential service for you and your family through Corporate Counseling Associates. This service is designed as an easy way for you to find help immediately for almost any need, such as taking care of yourself, personal or work-related stress, selecting the best caregiver for your child, researching assisted living facilities or home care, or identifying specialists to meet health and wellness needs and much more.”
Log in to the CCA-Work/Life Assistance web site here, Work/Life Assistance web site, and use the log-in code “ucs”.