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Get NY PS-404 2019

EMPLOYEE BENEFITS DIVISION HEALTH INSURANCE TRANSACTION FORM FOR NYS PE EMPLOYEES PS-404 9/17 INSTRUCTIONS READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES. EMPLOYEE INFORMATION 1. Employee Signature Required AGENCY USE ONLY Retirement Tier Registration HBA Signature Required Sick Leave Information Hours Hourly Rate of Pay Date Entered on NYBEAS Effective Date Instructions for NYS Health Insurance Transaction Form NYSHIP Program Information Resources To enroll in benefits or to change your current benefits you will most likely be required to submit proofs of eligibility for coverage or evidence of a qualifying event with the completed and signed Health Insurance Transaction Form PS-404. B. Voluntarily Cancel Coverage Vision 14 Qualifying Event NYS Department of Civil Service Albany NY 12239 Health Insurance Transaction Form Page 2 - PS-404 9/17 DEPENDENT INFORMATION Must be provided when choosing to enroll or opt-out of NYSHIP family coverage use additional sheets if necessary Check One A Add D Delete or C Change Check all that apply M Medical D Dental and V Vision A D C Relationship Address if different Sex M V Number ENTER ANNUAL OPTION TRANSFER REQUEST S BELOW Change NYSHIP Option Change to Elect Opt-out Change Pre-Tax Status Pre-Tax HMO Name PS-409 Opt-out Attestation Form. After-Tax Submit during the Pre-Tax Contribution Selection Period November 1-30 Personal Privacy Protection Law Notification The information you provide on this application is requested in accordance with Section 163 of the New York State Civil Service Law for the principal purpose of enabling the Department of Civil Service to process your request concerning health insurance coverage. Last Name First Name All employees must complete 2. Social Security Number MI 3. Sex Male Zip 4. Permanent Address Street City State 5. Mailing Address If different 6. Work Location Address 7. Date of Birth 9. Marital Status 8. Telephone Numbers Single 10. Covered under Medicare Married Self Primary Widowed Yes No Female Work Divorced Date Separated Spouse/Domestic Partner Child ELECT OR DECLINE COVERAGE A. Choose a Pre-Tax election Only eligible for Pre-Tax deductions if newly eligible or if requested during the PTCP election period Nov 1-30 Elect Pre-Tax Status for Premium deduction Elect After-Tax Status for Premium deduction B. Select a NYSHIP Coverage Option Choose option 1 2 3 or 4 1. Individual Enrollment 2. Family Enrollment Complete box 13 on page 2 3. Opt-out Program NYS Medical only 4. Decline Coverage Medical 10 Empire Plan HMO Code Select Empire Plan or HMO Name Individual Opt-out Family Opt-out Complete Box 13 If choosing Opt-out you must also complete the PS-409 Opt-out Attestation Form* Dental 11 Vision 14 CHANGE OR CANCEL EXISTING COVERAGE A. Change Coverage Change to FAMILY Complete box 13 Marriage Domestic Partner Newborn Request coverage for dependents not previously covered Previous coverage terminated proof required Dependent returned to full-time student status Dental and Vision only Other Date of Event Change to INDIVIDUAL Termination of Domestic Partnership Attach completed PS-425.

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