Health Benets Program
Application/Change Form
www.nyc.gov/olr
Employees
Return Form to:
Retirees (212) 513-0470
Return Form to:
For Domestic Partner
Changes - Return Form to:
Your Agency’s
Payroll or
Health Benefits Program
22 Cortlandt Street - 12th Fl.
New York, NY 10007
FAX: (212) 306-7756
Health Benefits Program 22
Cortlandt Street - 12th Fl.
New York, NY 10007
Attn: Domestic Partner Unit
Please print all information clearly using a black or blue ballpoint pen.
Applicant MUST check one:
q EMPLOYEE
q RETIREE
q RETURN TO RETIREMENT (Check this box if you were previously retired)
q LINE OF DUTY SURVIVOR
REASON(S) FOR SUBMISSION (Check one or more boxes. Enter change date, if appropriate)
A.
q
New Enrollment
q
Add Optional Benets*
B.
Change of:
C.
Transfer of Health Plan and/or
Optional/Benet Based on:
q
Reinstatement*
q
Waive Benets*
q Spouse/Domestic Partner: qAdd qDrop
q
Retirement EMPLOYEES ONLY: Effective Date: ______/______/______
q
Transfer Period
q
Disability Retirement*
q
Buy-Out Waiver Program
complete sections d, e, f & h
q Dependent Child(ren): qAdd qDrop q
Move Into/Out of Health Plan Area
q
Accident Disability Retirement
Effective Date: ______/______/______ Effective Date: ______/______/______
q
Drop Optional Benets*
q
Change of Name - Former Name:
q
Retiree Once-in-A-Lifetime
*Please indicate Effective Date: ______/______/______
____________________________________
Effective Date: ______/______/______
D. EMPLOYEE/RETIREE INFORMATION
Last Name: First Name: M.I.: Social Security Number or Employee ID Number:
- -
Home Address: Apt.: Pension Number:
City: State: Zip Code: Country (if outside the U.S.):
Date of Birth: Sex: Work - Telephone Number: Mobile\Home - Telephone Number: E-mail Address:
/ /
q
M qF
( ) - ( ) -
Marital
Status:
qSingle qMarried qDivorced
qWidowed qDomestic Partnership
Date of Event ( Agency in which employed or retired from: Union or Welfare Fund:
/ /
Name of current City Health Plan:
Are you Medicare eligible:
qYes qNo
If YES, please attach a copy of your Medicare card to this application.
E. SPOUSE/DOMESTIC PARTNER - ONLY COMPLETE IF YOUR SPOUSE/DOMESTIC PARTNER IS TO BE COVERED. IF NOT, LEAVE BLANK.
Last Name: First Name: M.I.: Social Security Number: Date of Birth:
- - / /
Sex: Is spouse/domestic partner:
qEmployed (Double City coverage is not permitted) qRetired (Double City coverage is not permitted) qNot Employed
qM qF
qCity Agency Name:__________________________________________________________________________ qNon-City Related
Does spouse/domestic partner have Non-City group health plan?
Is your spouse/domestic partner Medicare eligible:
qYes qNo
If YES, please attach a copy of his/her Medicare card to this application.
qYes qNo
F. FAMILY INFORMATION (Attach a second form if necessary; dependent may not be covered under two NYC Health Plans.)
List all eligible dependent children. Indicate if you are adding or dropping coverage by checking the appropriate box below.
*Attach a copy of Medicare card if
disabled dependent is Medicare eligible.
Dependent’s Last Name: Dependent’s First Name: Date of Birth: Social Security Number:
Sex:
/ / - -
q q q
/ / - -
q q q
/ / - -
q q q
/ / - -
q q q
/ / - -
q q q
G. HEALTH PLAN REQUESTED (Please print clearly)
FULL NAME OF HEALTH PLAN SELECTED: ____________________________________________________________________________________________________________
qYes qNo
H. EMPLOYEES ONLY (RETIREES ARE INELIGIBLE FOR THE HEALTH BENEFITS BUY-OUT WAIVER PROGRAM)
Employee Signature: Date:
I. TO PARTICIPATE IN THE HEALTH BENEFITS PROGRAM OR REQUEST CHANGES TO HEALTH COVERAGE
Furthermore, I agree that my periodic health plan deductions, if any, will be made on a pre-tax basis pursuant to the Internal Revenue Code 125. I understand that I have an option to
Employee/Retiree Signature: Date:
J. FOR COMPLETION BY PAYROLL OR PERSONNEL OFFICE ONLY
Agency Code: Title Code No.: Status: Appointment/Retirement Date: Pay Period:
q Full-Time q Permanent q Weekly q Monthly
q Part-Time q Provisional
/ /
q Bi-Weekly q Semi-Monthly
/ /
Retirement System (For Retiring Employees): Years of Credited Service: City Start Date: Retirement Date: Pension Number:
/ / / /
Certifying Signature: Date: Telephone Number:
/ / ( ) -
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