New York City Office of Labor Relations
Health Benefits Program
nyc.gov/hbp
RETIREE CHANGE OF ADDRESS FORM
A change of address may necessitate a change of health plans. Please check with your plan to see
if your NEW address is within their service area. If you need to change health plans as a result of
your new address, you must contact this office for further instructions. Please note that this form
only changes your address with the Health Benefits Program and your health plan. In order to
change your address with pension or your union, you will need to contact them directly.
Retiree Name: __________________________________________________________________________________________
Last First Middle Initial
S.S.N: __________________________________ Pension#:______________________________________________
New Address: ___________________________________________________________________________________________
Number and Street Apartment #
____________________________________________________________________________________________________
City State Zip Code
Current Health Plan: __________________________________________________________________________________
Telephone#: ____________________________________________________________________________________________
Area Code Phone Number
Cell Phone#: ____________________________________________________________________________________________
Area Code Phone Number
E-mail Address: ________________________________________________________________________________________
Signature: __________________________________________________ Date: ____________________________________
Do not mail this form.
Please submit this form electronically to:
https://nycemployeebenefits.leapfile.net
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