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INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES. EMPLOYEE INFORMATION (All employees must complete)

Last Name First Name MI

Social Security Number

Sex ☐ Male ☐ Female

Street Address City State Zip

Date of Birth

Telephone Numbers Home () Work ()

Work location and address

Marital Status ☐ Single ☐ Married

☐ Widowed

☐ Divorced ☐ Separated Marital Status Date

Covered under Medicare? Self ☐Yes ☐ No Spouse/Domestic Partner ☐Yes ☐ No

ENTER REQUEST(S) BELOW

☐ Request Enrollment- Individual Medical (10) (Select Empire Plan or HMO)

☐Empire Plan ☐ HMO* Code Name

☐ Dental (11) ☐ Vision (14)

☐ Request Enrollment- Family (Complete G) Medical (10) (Select Empire Plan or HMO)

☐Empire Plan ☐ HMO* Code Name

☐ Dental (11) ☐ Vision (14)

☐ Elect Pre-Tax Status for Premium deduction? ☐ Yes ☐ No If yes, initial here to indicate that you have read the Pre-Tax Contribution memorandum.

☐ Decline Coverage ☐Medical (10) ☐ Dental (11) ☐ Vision (14) (Process WAV/BEN transaction)

☐ Voluntarily Cancel Coverage ☐Medical (10) Qualifying Event: ☐ Dental (11) ☐ Vision (14)

☐ Change Coverage ☐Medical (10) ☐ Dental (11) ☐ Vision (14) Date of Event: ☐ Change to FAMILY (Complete G) ☐ Marriage

☐ Domestic Partner

☐ First dependent child acquired

☐ Dependent returned to full-time student status

☐ Request coverage for dependents not previously

covered

☐ Newborn

☐ Previous coverage terminated (Complete Section 11)

☐ Other

☐ Change to INDIVIDUAL

☐ I voluntarily cancel coverage for my dependents

☐ I voluntarily cancel coverage for my domestic partner

☐ Only dependent died

☐ Only dependent married

☐ Only dependent graduated

☐ Divorce

☐ Only dependent disqualified by age

☐ Termination of domestic partnership (Attach Completed PS-425.4)

☐ Other

G. DEPENDENT INFORMATION (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
☐ A

☐ D

☐ C

☐ M☐ D☐ V
* A completed HMO form must be attached.

10. Continued. ENTER REQUEST(S) BELOW H. ☐ Change Medical Benefit Plan Change to: ☐ Empire Plan ☐ HMO * Code HMO Name

* A completed HMO form must be attached.

I. Change Pre-Tax Status Change to: ☐ Pre-Tax ☐ Post-Tax Processed only by the Employee Benefits Division during the Pre-Tax Contribution Selection Period (November) 11. PREVIOUS COVERAGE INFORMATION If you were previously covered under NYSHIP or another health insurance plan (attach proof, i.e. insurance bill or letter stating former coverage), please complete this section. Previous ID Number Date Coverage Terminated
Enrollee’s Name Under Which Previously Covered Last First Middle Initial 12. LEAVE WITHOUT PAY AND RETIREMENT STATUS LEAVE WITHOUT PAY ☐ I wish to continue coverage while I am on authorized leave. I understand that I will be billed for this coverage. ☐ Medical ☐ Dental ☐ Vision ☐ I do not wish to continue coverage while I am on authorized leave. I wish to resume my coverage upon return to the payroll. ☐ Medical ☐ Dental ☐ Vision RETIREMENT ☐ I understand the requirements for continuing medical insurance coverage as a retiree and wish to continue my coverage. ☐ I understand the requirements for continuing medical insurance coverage as a retiree and wish to defer my coverage.

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