PRINTABLE FORMS

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AMERICAN FEDERATION OF STATE, COUNTY & MUNICIPAL EMPLOYEES / AFL-CIO

PRINTABLE FORMS

Underlined forms are down loadable and you will need Acrobat Reader to view and print them. If you do not have it, I have placed the free download link below. Please set printer for color for those forms that have the word (color) in parenthesis and remember that these forms take long to appear, once they are opened, if you have dial-up.

2021 Member Info Update
A 2021 update form to update a members records.

Affidavit of Stolen/Lost Drug I.D. Card (color)

A DC 37 form to be filled out by you and notarized to receive a duplicate Prescription drug card within 21 days.

Authorization for Deduction of Dues

Form for newly hired employees to fill out for the automatic deduction of union dues.

Beneficiary Designation

Any employee may change their beneficiary listed, with their employer, at any time or for any reason.

Change of Beneficiary Card

A form you fill out and sign in front of a Notary Public to change the recipient of your death benefits.

Change of Status Card

DC 37 form you fill out to inform the Union of change in marital, parental, name or address status.

CFI Prescription Refills

up to a 90 day supply of prescribed drugs(generically or you pay the difference unless not available in generic form) plus one refill for a one time co-payment of Five dollars.

DC 37 Health and Security Plan Lost Optical Voucher (color)

A Form you fill out and notarize in cases of lost, stolen or unused Optical Benefits Voucher within the 90 day period of grace.

Dental Form- Proposed Treatment or Statement of Claim

DC 37 form you and your Dentist fill out to approve work ahead of time or reimbursement of such work.

Direct Deposit Authorization to Members Bank Account(s)

Authorizes OTB payroll to direct deposit from members’ paycheck to members’ Bank account

Enrollment Card

The employee to establish benefits dependents and beneficiaries with D.C. 37 fills out this card. A must for a per diem newly converted to part-time status.

Grievance Form

A Local 2021 form you and the union fill out to address the violations of rules, regulations and/or contracts.

Health Benefits Application

City form to apply or change health benefits, add or drop optional riders and/or add or drop dependents.

Medical Release Form

DC 37 Health and Security Plan form to allow the union to release medical information to assist in claims.

Request for Direct Optical Reimbursement (color)

Fill out this DC 37 form to be reimbursed as per the schedule of rates set by DC 37.

Request for Optical Benefit Voucher (color)

DC 37 form you fill out for free examination, prescriptions, lenses and frames from participating optometrist, opticians and the DC 37 Vision Care Center.

Short-Term Disability Benefit Claim

A DC 37 form you and your doctor fill out after sustaining an injury or illness, that will prevent you from working for an extended period of time, and before returning to work.

Vacation Request Form

OTB form you fill out to request annual leave (presently a summer and winter form).

Claims received by DC 37 are frequently delayed or returned because they are incomplete. Your claim may be delayed or returned Unless you do the following:

Sign your name.
Give the phone number of your time keeper/payroll/personnel department.
Describe your illness.
Indicate if you were hurt at work.
Indicate if there is a lawsuit- if so, indicate the Attorneys' name, address and telephone number.
Make certain your social security number is correct.
Enclose a copy of your Marriage/Divorce/Separation papers if you have changed your name.
Attach an explanation to your claim if it is filed 15 or more days after the onset of your disability.
You must have a DC 37 Health and Security Plan Enrollment Card on file.

The Physicians Statement side of the claim form is to be entirely completed and only by your doctor.

You should not complete or alter any of the information in this section. Check particularly to be sure that your doctor includes dates of all treatments and expected duration of your disability.

If you leave the claim with your doctor, have it mailed to you before submitting so you can check for completeness.

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