Get Nysdcp Dc-4523 2019-2026

Filling out the NYSDCP DC-4523 online can streamline your submission process for insurance premium payment authorization. This guide will provide you with detailed, step-by-step instructions to ensure you complete the form accurately.

Follow the steps to fill out your insurance premium payment authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Enter your personal data in the specified fields. Print your name clearly, followed by your home address, date of birth, city, state, and zip code. Do not forget to include your home telephone number and your account number or the last four digits of your Social Security number.
3. Indicate if there is a change to your home address by marking the checkbox next to 'This is a change to my home address of record. Please update my account accordingly.'
4. In the payment method section, specify the amount to be transferred to your insurance carrier and select your preferred payment frequency, which can be one-time, monthly, quarterly, semi-annually, or annually.
5. Complete the premium due date field and provide the insurance carrier's name and mailing address. Make sure to enter the city, state, and zip code for the insurance carrier's address.
6. Attach a copy of the insurance premium notice to your submission, as this is required for timely processing. Your request may be delayed if this is not included.
7. In the authorization section, review the statements and acknowledge your certification as a qualified public safety officer. Ensure you sign the authorization section and enter the date.
8. Submit the completed form either by mailing it to the New York State Deferred Compensation Plan at the provided address or faxing it to the appropriate number, ensuring to follow the instructions for faxing.

Complete your NYSDCP DC-4523 form online today for efficient processing of your insurance premium payments.