WebNYS 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) Web3. Completed PS-425 Domestic Partner application and other required proofs as listed in the application. Domestic Partner Enrollment Packets may be obtained by contacting the …

EMPLOYEE BENEFITS DIVISION - State University of New York

WebNYSHIP Application for Enrolling Domestic Partners (PS-425) State employees apply for enrolling domestic partners in NYSHIP and affidavit of domestic partnership. Download … WebFollowing your initial eligibility for health insurance, you may want to enroll in a NYSHIP plan, cancel coverage or make changes to your current plan. ... (PS-425.4) None: No deadline: Determined upon review: I Want to Remove a Dependent. I Want to Change from Family to Individual Coverage . family life services ypsilanti

Other NYSHIP programs SUNY Geneseo

WebOnce your PS-406.2 has been processed you will receive a PS-410 Form - State Service Sick Leave Preservation which documents your request to preserve your sick leave for later use. Keep a copy of this form for your records. It is your responsibility to provide this form to Civil Service when you reactivate your NYSHIP benefits. WebNYSHIP coverage through another employer, such as a municipality, ... (PS-404) NYSHIP Termination of Domestic Partnership (PS-425.4) None: No deadline: Determined upon review: I Want to Remove a Dependent. I Want to Change from Family to … Webaffirmation to NYSHIP that I am not subject to federal tax withholding for any imputed income resulting from benefits extended to my Domestic Partner. I understand that I will … cool bedroom chairs for teens