Get Nys Government Employees Health Insurance Coordination Of Benefits Form. Sunycap Conf Reg Form

This guide provides clear and detailed instructions on how to complete the NYS Government Employees Health Insurance Coordination of Benefits Form online. The process is straightforward and designed to help you navigate each section with ease.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your online editor.
2. Begin with Section I - Employee Information. Fill in your first name, last name, and middle initial. Then select the relevant prefix (Mr., Ms., etc.). Next, enter your Social Security number and date of birth. Indicate your gender by circling the appropriate option: Male, Female, or Other. Complete your marital status by selecting either Single or Married.
3. Provide your street address, city, state (NY or PA), and zip code. Identify your employing agency and include the agency code.
4. Move to Section II which focuses on other coverage. Start with Other Coverage A. Enter the name of the dependent who has other coverage, along with their policy number or identification number.
5. Fill in the name and address of the other employer, followed by the name and address of the other insurance carrier. Specify the type of coverage (Individual or Family) and record their date of birth and gender.
6. If there are additional dependents with other coverage, check the corresponding box and repeat the information for Other Coverage B as necessary.
7. After completing all sections, ensure to review the entire form for accuracy. Sign and date the form in the designated area at the bottom.
8. Finally, save your changes, and you will have the option to download, print, or share the completed form as needed.

Complete your documents online today for a hassle-free experience.