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Dental & Vision Insurance Forms

Ms. Jennifer Costanzo, Director of Operations for Promark Insurance Services gave a presentation at the State Board meeting held on December 3rd.

Promark was contracted to handle the serving of the NYSTPBA sponsored dental and vision insurance program. The contract with EPIC Insurance was recently terminated and Promark will handle the transition until further notice.

Ms. Costanzo provided the following information:

For your use and distribution to the group, attached please find the Delta Dental Benefit Summary, VSP Vision Benefit Summary, Delta Enrollment form and VSP Enrollment form. Also attached is the Beneration withdrawal form for enrollees in either or both plans. Rates for the plans are listed below and are unchanged from the 2022 term. For the Dental monthly: Enrollee only: 44.11 Enrollee + 1: 95.62 Enrollee + 2 or more: 159.89 For the Vision monthly: Enrollee only: 8.60 Enrollee + 1: 13.77 Enrollee + Children: 14.05 Enrollee + Family: 22.66 If you (or any member) have any questions or concerns about this program or other insurance needs, please let me know. We are working on healthcare alternative options and can assist with medicare on the Sheridan Benefits side. On my side of the house, we can help with personal and commercial insurance needs, too. Thank you very kindly and thank you for sharing the information! Jenn Jennifer Costanzo, CRIS® Risk Manager Director of Operations 716.633.8401 Buffalo Office 216.367.2500 Cleveland Office 716.310.3895 Cell 716.633.8429 Fax

Any questions can be directed to Ms. Costanzo above or the NYSTPBA:

PBA Office Monday through Friday 8:00 am – 4:00 pm 120 State Street; 2nd Floor Albany, New York 12207 Office: 518.462.7448 Fax: 518.462.0790

Delta Dental NYS-TPBA Benefit Summary
Download PDF • 275KB

Download DOCX • 28KB

Form_ Individual Membership Enrollment VSP
Download DOCX • 148KB

VSP Vision Benefit Summary
Download PDF • 922KB

Delta Enrollment Form_writable
Download PDF • 39KB

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