Form Ps-404 - Nys Health Insurance Transaction Form

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EMPLOYEE BENEFITS DIVISION
NYS HEALTH INSURANCE TRANSACTION FORM
PS-404 (9/15)
INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES.
EMPLOYEE INFORMATION
(All employees must complete)
1. Last Name
First Name
MI
2. Social Security Number
3. Sex
Male
Female
4. Street Address
City
State
Zip
5. Date of Birth
6. Telephone Numbers
7. Work location and address
Primary (
)
Work (
)
8. Marital Status
Married
Divorced
Marital Status Date
Single
Widowed
Separated
9. Covered under Medicare?
Self:
Yes
No
Spouse/Domestic Partner:
Yes
No
Child:
Yes
No
10.
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)
Date of Event
Check all that apply: M (Medical), D (Dental), and V (Vision)
Social Security
Last Name
First Name
MI
Relationship
Date of Birth
Sex
Address (if different)
Number
A
M
D
D
C
V
A
M
D
D
C
V
A
M
D
D
C
V
A
M
D
D
C
V
11.
NEW OR NEWLY ELIGIBLE EMPLOYEES: CHOOSE ONE OF THE FOLLOWING OPTIONS (A, B OR C)
A. Enroll in NYSHIP Coverage: Choose options 1 or 2 and complete box 3
Medical
(Select Empire Plan or HMO)
(10)
Dental
Vision
1. Individual Enrollment
(11)
(14)
Empire Plan
HMO Code
Name _______________
Medical
(Select Empire Plan or HMO)
2. Family Enrollment
(10)
Dental
Vision
(11)
(14)
(Complete box 10)
Empire Plan
HMO Code
Name _______________
3.
Elect Pre-Tax Status for Premium deduction
Elect Post-Tax Status for Premium deduction
Please read the Pre-Tax Contribution program materials.
B. Elect the Opt-out program (if eligible): Complete boxes 1 and 2
1.
Individual Opt-out
Family Opt-out
If choosing Opt-out, you must also complete the PS-409 Opt-out Attestation Form.
2.
Elect Pre-Tax Status for Premium deduction
Elect Post-Tax Status for Premium deduction
Please read the Pre-Tax Contribution program materials.
C. Decline NYSHIP Coverage
Medical
Dental
Vision
(10)
(11)
(14)
12.
TO CHANGE OR CANCEL COVERAGE CHOOSE FROM THE BOXES BELOW
A. Change Coverage:
Medical
Dental
Vision
Date of Event:
(10)
(11)
(14)
Change to FAMILY (Complete box 10)
Change to INDIVIDUAL
Marriage
Divorce
Domestic Partner
Termination of Domestic Partnership (Attach completed PS-425.4)
Newborn
Only dependent ineligible due to age
Request coverage for dependents not previously covered
I voluntarily cancel coverage for my dependents
Previous coverage terminated (proof required)
Only dependent died
Dependent returned to full-time student status
Only dependent married (Dental and Vision only)
(Dental and Vision only)
Only dependent graduated (Dental and Vision only)
Other
Other
B. Voluntarily Cancel Coverage:
Medical
Dental
Vision
Qualifying Event:
(10)
(11)
(14)
NOTE: If you are enrolled in the Pre-Tax Contribution Program, your ability to make mid-year changes may be limited.

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