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Get Ny Ps-404 2017
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How to fill out the NY PS-404 online
The NY PS-404 is a vital form used for health insurance transactions for employees in New York State. This guide provides step-by-step instructions on how to accurately complete the form online, ensuring you can enroll in health insurance coverage effectively.
Follow the steps to successfully complete the NY PS-404 online.
- Use the 'Get Form' button to obtain the NY PS-404 and open it in your preferred online editor.
- Begin by filling out the employee information section in boxes 1-9. Provide your first name, last name, middle initial, date of birth, sex, social security number, street address, city, state, zip code, and telephone numbers. Make sure all information is entered accurately.
- In box 10, check the appropriate boxes to add, delete, or change dependent information. Fill out all required fields for each dependent including their last name, first name, middle initial, relationship, date of birth, sex, and any special coverage requirements.
- For new or newly eligible employees, complete box 11 (A-C). Select options for medical, dental, and vision coverage. Specify whether you are opting for individual or family enrollment and indicate your preference for pre-tax or post-tax contributions.
- In box 12, indicate any changes or cancellations to your coverage. Specify whether you are changing from individual to family coverage, or cancelling coverage altogether, and include the date of the event that prompted the change.
- Box 13 is for annual option transfer requests. Use this box to indicate if you are changing your NYSHIP option or your pre-tax status during the designated time period.
- In box 14, provide information regarding your status during a leave without pay or if you are retiring. Specify whether you wish to continue or cancel your health coverage.
- Finally, review all entries for accuracy. Ensure you’re providing any required documentation, and sign and date the authorization section at the end of the form.
- Once completed, you can save your changes, download, print, or share the completed form as necessary.
Complete your health insurance transactions online by filling out the NY PS-404 today.
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Empire insurance is often referred to as the Empire Plan or the New York State Empire Plan. This plan provides comprehensive health coverage for New York state employees and their eligible dependents. Being familiar with the alternative names helps in navigating insurance documents and services more efficiently. For detailed insights into this plan, resources related to NY PS-404 would be beneficial.
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