The following forms are available for downloading:

Activity Report: Use this form to report all additions, terminations and changes on your policies through BSNY.

Electronic Debit Form: Use this form to have your monthly or quarterly payment electronically debited from your company account.

Census Form: Fill out this form to obtain a quote for certain BSNY products.

ChamberFlex Participation Form: Use this to enroll in your company's Cafeteria Plan.

Flexible Benefit Plan Reimbursement Claim Form: Use this to submit claims for reimbursement for either medical reimbursement or dependent care accounts.

These forms are PDFs and can be viewed and printed with Acrobat Reader. If you do not have Adobe Reader, click to download now.

Forms FAQs

Q: What is Electronic Debiting?
A: In an effort to further simplify health insurance administration, BSNY is offering an Electronic Debiting service. Electronic Debiting is the simplest, fastest and easiest way of paying your monthly health insurance bill. Consider these advantages:

• Worry-Free Processing. You never have to worry if you’ve misplaced your bill or whether it has been paid and mailed on time. No late notices or penalties!
• No Check Writing. Electronic Debiting authorizes necessary funds to be automatically transferred from your designated checking account.
• Saves Money: No stamps or envelopes are required.
• Automated Record Keeping. You will receive a detailed description of the transaction on your bank statement. It will show the amount and date of transfer and the authorized party who initiated the transaction.
  

Q: Will I still receive a monthly or quarterly bill?
A: Yes. Monthly or quarterly bills will continue to be mailed on the 10th of each month. Any activity (additions, terminations and changes) submitted to BSNY before the 5th will be reflected on your bill.

Q: What do I do with additions, terminations and changes?
A: In any month where activity occurs, remit the necessary forms, etc. to BSNY. This activity will be processed upon receipt. Any activity not processed by the 5th will be reflected in your next monthly bill.

Q: What if I change my checking account in the future?
A: You should notify BSNY as soon as practical, preferably 30 days in advance of the next debit. You will need to fill out a new Authorization form and provide a new voided check.

Q: How Do I Start Electronic Debiting?
A: First, complete the online form, “Authorization Agreement for Preauthorized Payments (Debits)”. Then, send in a blank check from the business checking account from which you desire the electronic debits to be made from. Write “Void” on the blank check.