Female City State Zip Last Name 6. Telephone Numbers Home ( ) 8. Marital Status Single Married Widowed 9. Covered under Medicare? Divorced Separated Self Yes 10. A. Work location and address ) Marital Status Date No Spouse/Domestic Partner/Dependent? Yes No ENTER REQUEST(S) BELOW (Select Empire Plan or HMO) Request EnrollmentIndividual B. 7. Work ( Empire Plan HMO* Code Name (Select Empire Plan or HMO) Request EnrollmentFamily (Complete G) Empire Plan C. Elect Pre-T.
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How to fill out the Ps 404 Pe Form online
Filling out the Ps 404 Pe Form online is a crucial step for users seeking health insurance coverage through the New York State Department of Civil Service. This guide will provide clear, step-by-step instructions to help you complete the form accurately and efficiently.
Follow the steps to complete the Ps 404 Pe Form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling out the employee information section. This includes your first name, middle initial, last name, social security number, sex, date of birth, and contact information such as your street address, city, state, and zip code.
- Indicate your marital status by selecting from the options: single, married, widowed, divorced, or separated. Ensure to check the appropriate box.
- Respond to the question regarding Medicare coverage by selecting 'Yes' or 'No' based on your situation.
- In the request section, select the type of enrollment you are applying for (individual or family) and provide the corresponding details for the Empire Plan or HMO.
- You may also choose to elect pre-tax status for premium deductions if applicable. Verify with your agency whether this option is available.
- If you are making changes to existing coverage, complete the dependent information section by checking whether to add, delete, or change coverage for dependents.
- Complete any sections regarding previous coverage, if relevant, and provide necessary details and documentation.
- Review the leave without pay and retirement status options, and select your preference for continuing coverage during those periods.
- If requesting an Empire Plan card, indicate whether it is for you or your dependents, and mark if you need a duplicate or replacement card.
- Finally, review the authorization section, confirm the accuracy of the information, then provide your signature and the date to complete the form.
- Once all sections are filled out, you can save changes, download, print, or share the form as needed.
Complete your Ps 404 Pe Form online today to ensure you have the necessary health insurance coverage.
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How to opt out of NYS health insurance?
You must submit a completed Health Insurance Transaction (PS-404) and Opt-out Attestation (PS-409) forms to us to enroll in the Opt-out program. Please note, it is no longer necessary to re-enroll in the Opt-Out program each year.
What is a ps404?
Use to enroll, decline, change, or opt-out of coverage. Health Insurance Transaction Forms (PS-404 & PS-409)
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