Get Ny Form 1054 2011-2025

Filling out the NY Form 1054 online can streamline your health benefits inquiry and ensure that your submission is processed efficiently. This guide provides clear and detailed instructions to help you navigate each section of the form with confidence.

Follow the steps to complete your NY Form 1054 online.

1. Click ‘Get Form’ button to access the document and open it in your preferred digital format.
2. Indicate the recipient by checking one of the boxes for 'Employee' or 'Retiree' at the top of the form. If this is a second request, also check that box.
3. Select the appropriate health plan from the list provided. Options include various plans like AETNA HMO, CIGNA Healthcare, and Empire EPO. If your plan is not listed, write it in the space provided.
4. In the 'Reason(s) for Submission' section, check one or more boxes to indicate your purpose for submitting the form, such as status changes, reinstatement, or claims inquiries.
5. Fill in your personal information in the 'Employee Information' section, including your last name, first name, middle initial, social security number, and home address.
6. Complete the 'Employee Payroll Information' section by providing details like agency code, job title, and pay period frequency.
7. If applicable, fill in the 'Explanation Inquiry' section and provide any necessary additional details that may help in processing your inquiry.
8. Before submitting the form, ensure all information is accurate and complete. Save your changes, and then you can download, print, or share the form as needed.

Complete your NY Form 1054 online now for a smoother inquiry process.