Health & Welfare Fund
Police Benevolent Association of the City of New York, Inc.
125 Broad Street, 11
New York, NY 10004
Phone: (212) 349-7560
Fax: (212) 437-9480
Please use this form to update your mailing address. Be sure to fill out this form both accurately and
completely, as it is essential that the PBA Funds Office has your most up to date information to
administer your Health and Welfare benefits to you and your eligible dependents.
Please be aware that you must also update your information with the City of New York separately. The
PBA Funds Office and the City of New York do not share or exchange any of your information.
Last 4 Digits - SSN
Effective Date Of Change:
Do you have eligible dependents who do not live with you?
If you have eligible dependents who do not currently live with you, please complete the “Dependent(s)
Information:” section on page 2. If your eligible dependents live with you please disregard page 2 of this
Change of Address Form