Webother employer sponsored group health insurance. Employees must complete a PS-404 and provide proof of the qualifying event within 30 calendar days or they will not be able may re-enroll in NYSHIP until the annual Option Transfer Period. Employees must re-enroll in the Opt-Out Program during the annual Option Transfer Period to continue to remain WebNYS Health Insurance Transaction Form for Retirees, Vestees, Preferred List and Dependent Survivors PS-404R (3/18) INSTRUCTIONS: READ AND COMPLETE BOTH …
Ps 404: Fill out & sign online DocHub
WebDownload the NYSHIP Health Insurance Enrollment or Change Form (PS-404) Mobile Users. For the best experience in completing this form use a non-mobile device. Using Firefox with PDF forms? Make Adobe Acrobat the reader. Completing the PDF Form . Read through all pages of the document to find specific instructions, if any; WebNYSHIP Health Insurance Transaction Form . for NYS & PE Employees . PS -404 (1 /202 3 ) EMPLOYEE INFORMATION 1. Last Name First Name MI . 2. Social Security Number . … spin wheel design template
Health Insurance Transaction Form PS-404 Human Resources
WebFor active NYS employees, not yet retired, this form is used to change your address with the retirement system. Download. ... Documentation Requirements for the Health … WebTo Apply for the 3-Month Extension Of Free NYS Dental and Vision Dependent Coverage: 1. Complete a New York State Health Insurance Transaction Form(PS-404) • On page 1, fill in #1-6. Under Dependent Information, list . only . the dependent ineligible for dental/vision coverage. To the left of his or her name, check “D” WebNYS HEALTH INSURANCE TRANSACTION FORM PS-404 (9/15) INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. ... NYS Department of Civil Service Health … spin wheel games on internet