WebFill Nys Ps 404 Form, Edit online. Sign, fax and printable from PC, iPad, ... NYSHIP PS-404 PS409 Attestation EnrollmentIndividual PS-425 1st EnrollmentFamily Related Forms - ps 404r form ... WebPS-404 (3/17) INSTRUCTIONS: ... 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 ... (Attach completed PS-425.4) Only dependent ineligible due to age I voluntarily cancel coverage for my dependents

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 … st joseph\u0027s rathmullan live streaming

EMPLOYEE BENEFITS DIVISION NYS HEALTH INSURANCE TRANSACTION FORM PS …

WebTermination of Domestic Partnership for NYSHIP PS-425.4 (3/17) I, certify that: Name of Enrollee (Please Print) I, and Name of Enrollee (Please Print) Name of Domestic Partner (Please Print) have terminated our domestic partnership. I affirm that the effective date of termination of this domestic partnership is: Date WebTermination of Domestic Partnership for NYSHIP (PS-425.4) form within 30 days of the date the relationship ends or can no longer be documented. To access one of the domestic partner forms, go to www.cs.ny.gov and select Retirees and then Health Benefits. Choose NY and HMO Enrollee, and from the NYSHIP Online homepage, select Forms and WebYou add a newly-eligible dependent to your coverage. A list of the dependents and the necessary documentation can be found in the NYSHIP book. Please note that newborn … st joseph\u0027s rc church aylesbury