To enroll and complete a paper enrollment form HERE and you may fax or mail to the UUP Benefit Trust Fund.

Fax: 1-866-559-0516 Mail: Benefit Trust Fund , PO Box 15143, Albany, NY 12212-9954 Email: Benefits@uupmail.org

The UUP Benefit Trust Fund (Fund) provides dental and vision coverage for UUP-represented employees in the Professional Services Negotiating Unit who are eligible for NYSHIP under the UUP/NYS collective bargaining agreement.

This form must be received by the Fund before benefits can be accessed. Completion of this form does not imply eligibility. You may verify eligibility by calling the Fund or checking with your campus Health Benefits Administrator (HBA)

DeltaCare USA DHMO Option: If you are a new employee, or have never enrolled in the Fund, you may select the Delta DHMO by filling out the DHMO enrollment card. If you do not select the Delta DHMO, you will automatically be enrolled in the Delta PPO.

Employee Information:

Spouse \ Domestic Partner Information:

Please Select One:

Dependent Children Information

Enter Dependent Children Information:   (HERE)

DEPENDENT #1

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #2

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #3

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #4

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #5

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #6

First name:
Last name:
Middle:
Gender:
Date of Birth:

Enter Additional Dependent Children:   (HERE)

DEPENDENT #7

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #8

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #9

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #10

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #11

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #12

First name:
Last name:
Middle:
Gender:
Date of Birth:

NOTE: UUP-represented employees who defraud or attempt to defraud the UUP Benefit Trust Fund (Fund) or who knowingly give false or misleading information are subject to a penalty, which may include suspension of eligibility for all Fund benefits. UUP-represented employees are responsible for notifying the Fund of any changes in marital and/or dependent status by submitting a Change of Status Form, which is available from the Fund office.

*Acceptance of Terms

YES! I Agree that submission of this form constitutes your consent to online enrollment in vision and dental benefits provided by the UUP Benefit Trust Fund. You will receive an e-mail confirming receipt of this enrollment form. Please retain a copy of that e-mail for your records.

* Required