OSA Welfare Fund Forms

On this page you will be able to download a number of welfare fund forms as pdf files. To read and print pdf files you will need Adobe Reader on your hard drive. To download a free copy of Acrobat Reader click here. Please follow all instructions for properly installing Adobe Reader on your computer.

OSA Welfare Fund Vital Data Sheet
A form for your basic identification information. If you are a new OSA member, or your information has changed, please complete and return the form to the union. You can obtain a copy as a pdf file by clicking here.

Dental Benefits
Dental benefits are described in the OSA Welfare Fund booklet, which you can download from the OSA Welfare Fund Benefits page on this site. You can link to the Self-Insured Dental Services website from that location as well. At the SIDS site you can determine your eligibility, find plan providers and print out plan descriptions and forms.

OSA Dental Claim Form
To make a claim when using a non-participating provider, download this form by clicking here. You don't need to use the form if you use a participating provider. However, when using a non-participating provider, you must complete the form, which can be used for any dentist.

Optical Benefits
Vision care benefits are provided through DavisVision. You may directly link to their website from the OSA Welfare Fund Benefits page. At their site you can search for the most up-to-date participating providers by zip code or within a specific mile radius of that zip code. You do not need a form if you are using a participating vision provider.

The Direct Reimbursement Vision Claim Form
When you are using a non-participating vision care provider, you must use this form, which you may download by clicking here. Be sure to complete all information required, then sign and have the provider sign the form in the spaces provided. Submit the form to DavisVision, Vision Care Claim Form, PO Box 1525, Latham NY 12110. If you have questions about the form, contact DavisVision at 800-999-5431.

COBRA Application
An application for COBRA can be made when the dependent reaches age 23 or leaves school and/or marries. COBRA coverage lasts for 18 months. To obtain more information about COBRA and a COBRA application click here.

Basic Life Insurance
OSA provides basic life insurance with $50,000 worth of coverage for active members and a lower level of coverage for retirees - and it's free! As with all life insurance policies, a beneficiary must be designated.

The Group Enrollment Form available by clicking here should be printed out, completed and returned to OSA. If you have previously filled out a beneficiary form but have not updated it within the past few years, please download the form, print it, complete it and return it to the union with your current preferences. The insurance company prefers a recent beneficiary form to be be on file.

To obtain a copy of the policy certificate booklet, phone OSA at (212)686-1229.

Supplemental Group Term Life Insurance
Additional group term life insurance is available to you as an option. For more information consult the Additional Benefits page on this website.

Superimposed Major Medical
Superimposed Major Medical coverage is designed for one of two possible, but uncommon situations. If your medical bills are very high, in any one year, and your basic carrier (GHI, HIP, etc.) has reimbursed you, but not fully, the Superimposed Major Medical comes to your assistance. There is a deductible. As a result, few members normally make use of this benefit. It is a real help, however, when you face catastrophic medical bills. The second uncommon situation relates to psychiatric treatment. Once you have exhausted your basic carrier's psychiatric coverage, and after satisfying the Major Medical Deductible, OSA Welfare Fund's Superimposed Major Medical coverage may provide additional benefits. The Superimposed Major Medical Claim Form can be downloaded by clicking here.

Long Term Disability
Long Term Disability is claimed by about one in 2,000 members each year. As a result, we are not providing forms for LTD on this site. You may be eligible for LTD if you are out of work due to illness for six months. If you're in need, call, not only for the form, but also for a discussion of the somewhat complex aspects of such cases: Leave of Absence requirements, COBRA, other available benefits, etc. But don't wait for the six months to be up to call for the form and to discuss the situation. Give us a call when you've been out for four months, or as soon as you know you'll be out for more than six months, so you can get a head start on the planning and paperwork.

Many members leave pay status and are entitled to continue their OSA Welfare Fund benefits through direct payment to the Welfare Fund, that is, through COBRA payments. To obtain more information about all aspects of COBRA and to obtain a COBRA application, click here.

Young Adult Dependent Coverage
Congress and the New York State legislature have each passed laws that will allow certain young adult dependents of employed or retired parents to continue their basic health care coverage until they are 26 (under the federal law) or 30 years of age (under the NYS law). The OSA Welfare Fund will extend its coverage to young adult dependents of active or retired members following the same guidelines. You should consult page 15 of the OSA Welfare Fund booklet for more information, as well as the packet of information and forms that you can download by clicking here.