FORMS NEEDED FOR ENROLLMENT:

1. ​MTABF Enrollment & Change of Life Form ***
2. Dental Enrollment Announcement 
3. Dental Enrollment ***
4. Claim Form (only if enrolling dependents in dental)  ***
5. Dental Claim Form ​
6. Dental Providers 
7. Vision Enrollment ***
8. Vision Benefit Assignment Authorization Form
9. Hearing Aid Benefit Assignment Authorization Form
10. Life Coverage Info Letter 
11. Life Insurance Enrollment & Change of Beneficiary ***
12. I Have Life Insurance  ​
13. Financial Counseling Summary
14. Legal Overview Information ​​​
15. Major Medical Reimbursement 
16. Important Contacts Info 
17. Benefits Booklet 

 *** These forms & documentation must be returned via inter-office mail to Charles Jensen at the Middle School or mail  to:
MTABF
P.O. Box # 656
Baldwin Place, NY 10505 

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Mahopac Teachers Association Benefit Fund
P.O. Box # 656
Baldwin Place, NY 10505
​Phone: 845.543.7415

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