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Get NY Health Benefits Application 2012

or more boxes: enter change date if appropriate) A. New Enrollment Reinstatement Retirement Disability Retirement  Accident Disability Retirement Drop Optional Benefits Add Optional Benefits Cancel Benefits (Check one) Waive Benefits Buy-Out Waiver Program (Employees only) (Complete Sections D, E, F & I only) Other B. Transfer of Health Plan and/or Optional Benefits Based on: Transfer Period Permanent Move Into/.

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