Fillable HEALTH INSURANCE TRANSACTION FORM Street INSTRUCTIONS: READ AND (City University of New York)

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HEALTH INSURANCE TRANSACTION FORM Street INSTRUCTIONS: READ AND (City University of New York)

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EMPLOYEE BENEFITS DIVISION
HEALTH INSURANCE TRANSACTION FORM
FOR NYS & PE EMPLOYEES
PS-404 (9/17)
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
4. Permanent Address
Street
City
State
Zip
5. Mailing Address (If different)
Street
City
State
Zip
6. Work Location & Address
Street
City
State
Zip
7. Date of Birth
8. Telephone Numbers
Primary Work
9. Marital Status
Single Married Widowed Divorced Separated
Marital Status
Date
10. Covered under Medicare? Self: Ye s No Spouse/Domestic Partner: Yes No Child: Yes No
11. ELECT OR DECLINE COVERAGE
A. Choose a Pre-Tax election
(Only eligible for Pre-Tax deductions if newly eligible or if requested during the PTCP election period, Nov 1-30)
1. Elect Pre-Tax Status for Premium deduction 2. Elect After-Tax Status for Premium deduction
B. Select a NYSHIP Coverage Option (Choose option 1, 2, 3 or 4)
1. Individual Enrollment
Medical
(10) (Select Empire Plan or HMO)
Empire Plan HMO Code Name _______________
Dental (11) Vision (14)
2. Family Enrollment
(Complete box 13 on page 2)
Medical
(10) (Select Empire Plan or HMO)
Empire Plan HMO Code Name _______________
Dental (11) Vision (14)
3. Opt-out Program
(NYS Medical only)
Individual Opt-out Family Opt-out (Complete Box 13)
If choosing Opt-out, you must also complete the PS-409 Opt-out Attestation Form.
Dental (11) Vision (14)
4. Decline Coverage
Medical (10) Dental (11) Vision (14)
12.
CHANGE OR CANCEL EXISTING COVERAGE
A. Change Coverage:
Medical (10) Dental (11) Vision (14)
Date of Event:
Change to FAMILY (Complete box 13)
Marriage
Domestic Partner
Newborn
Request coverage for dependents not previously covered
Previous coverage terminated (proof required)
Dependent returned to full-time student status
(Dental and Vision only)
Other:
Change to INDIVIDUAL
Divorce
Termination of Domestic Partnership (Attach completed PS-425.4)
Only dependent ineligible due to age
I voluntarily cancel coverage for my dependents
Only dependent died
Only dependent married (Dental and Vision only)
Only dependent graduated (Dental and Vision only)
Other:
NOTE: If you are indicating a change in marital status to Divorced or Separated, please be sure to update the address information for the dependent in Box 13 if applicable.
B. Voluntarily Cancel Coverage: Medical (10) Dental (11) Vision (14) Qualifying Event:
NOTE: If you are enrolled in the Pre-Tax Contribution Program, you may make changes during the Annual Option Transfer Period or when experiencing a qualifying event.
(NOTE: HMO and Opt-out not available to CUNY)
NYS Department of Civil Service Health Insurance Transaction Form
Albany, NY 12239 Page 2 - PS-404 (9/17)
13.
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)
Check all that apply: M (Medical), D (Dental), and V (Vision)
Date of Event:
Last Name First Name MI Relationship Date of Birth Sex
Address (if different)
Social Security
Number
A
D
C
M
D
V
A
D
C
M
D
V
A
D
C
M
D
V
A
D
C
M
D
V
14.
ENTER ANNUAL OPTION TRANSFER REQUEST(S) BELOW
Change NYSHIP Option
Change to:
Empire Plan HMO Code HMO Name:
Elect Opt-out
(NYS Medical only)
Individual Opt-out Family Opt-out
If choosing Opt-out, you must also complete the
PS-409 Opt-out Attestation Form.
Change Pre-Tax Status
Change to:
Pre-Tax After-Tax
Submit during the Pre-Tax Contribution
Selection Period (November 1-30)
Personal Privacy Protection Law Notification
The information you provide on this application is requested in accordance with Section 163 of the New York State Civil Service Law for
the principal purpose of enabling the Department of Civil Service to process your request concerning health insurance coverage. This
information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e) and
(f). Failure to provide the information requested may interfere with our ability to comply with your request. This information will be
maintained by the Director of the Employee Benefits Division, NYS Department of Civil Service, Albany, NY 12239. For information
concerning the Personal Protection Law, call (518) 473-2624. For information related to the Health Insurance Program, contact your
Health Benefits Administrator. If, after calling your Health Benefits Administrator, you need more information, please call (518) 457-5754
or 1-800-833-4344 between the hours of 9:00 a.m. and 4:00 p.m. Eastern time.
AUTHORIZATION
I have read the Pre-Tax Contribution Program materials and the Opt-out Attestation Form (if applicable), and have made my selection on
Page 1 of this document. I understand that if my coverage is declined or canceled, I may subject myself and/or my dependents to waiting
periods if I decide to enroll at a later date and may forfeit the right to such coverage after leaving State service (vest, retirement, etc.). I
am aware of how to obtain a current Summary of Benefits and Coverage for the NYSHIP option I have selected. I understand that my
failure to provide required proof(s) within 30 days may delay the availability of benefits for me or any dependent for whom I fail to provide
such proof. Any person who makes a material misstatement of fact or conceals any pertinent information shall be guilty of a crime,
conviction of which may lead to substantial monetary penalties and/or imprisonment, as well as an order for reimbursement of claims.
I certify that the information I have supplied is true and correct. I hereby authorize deduction from my salary or retirement
allowance of the amount required, if any, for the coverage indicated above.
Employee Signature (Required): Date:
AGENCY USE ONLY
Retirement Tier Registration #
Sick Leave Information
Date Entered on
NYBEAS
Effective Date
# Hours Hourly Rate of Pay
HBA Signature (Required): Date:
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HEALTH INSURANCE TRANSACTION FORM Street INSTRUCTIONS: READ AND (City University of New York)

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Completed 18 December 2020

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