Nyship Transfer
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1NEW YORK STATE HEALTH INSURANCE PROGRAM
(NYSHIP)
TRANSFER FORM
Transfer to New College / Change in Title Form
If you are currently enrolled in NYSHIP and will be transferring to a new college, will have a new title or
both, you must complete this form. This will ensure your NYSHIP coverage remains uninterrupted and
you maintain continuity of benefits. Delays in completing this form may jeopardize health insurance
coverage.
Section A: Reason for Submission (check one):
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Both Transfer & Change in Title
Transfer Only
Change in Title Only
Section B: Employee Information
Name
:
NYSHIP Card #: __________
(Please Print)
(Last, First)
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Last or Current Appointment (check one):
Spring
Summer
Fall
Year: _______
College:
Appointment Date:
Month/Day/Year
Title:
Section C: New Appointment / Title Information (check one):
□
□
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Spring
Summer
Fall
Year: _______
College:
Appointment Date:
Month/Day/Year
Title:
By signing below, I attest that the information above regarding my new appointment or change in title is
accurate, and that I approve the transfer of my health insurance deductions from my current paycheck to
the paycheck associated with my new appointment or title change.
Signature
Date
Phone Number
If you are a student at the CUNY Graduate Center, you may email the form to Scott Voorhees at
healthinsuranceinfo@gc.cuny.edu
or fax it to 212-817-1621. Mr. Voorhees may be reached by telephone
at 212-817-7406.
If you are an Engineering Ph.D. Student at City College, you may email the form to Kim Ferguson at
kferguson@ccny.cuny.edu
or fax it to 212-650-7504. Ms. Ferguson may be reached by telephone at
212-650-7963.
NYSHIP 001TRF –UBO UpdatedJAN2012
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