NYSHIP Health Insurance Enrollment or Change Form (PS-404)

State employees enroll or submit changes for NYSHIP health insurance.

Download the Form

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Completing the PDF Form

  1. Read through all pages of the document to find specific instructions, if any
  2. Enter requested information into the form
  3. Print the form
  4. Get required signatures
  5. Scan a copy of the signed form for your records
  6. Send the original, completed, signed form to:         

Human Resources
120 Crofts Hall
2020欧洲杯体育直播投注 North Campus

to enroll family members include copies of:

For Spouse

 - marriage certificate

 - birth certificate

2020欧洲杯体育直播投注 - social security number

2020欧洲杯体育直播投注 - if married more than 1 year proof of financial interdependance

For Children

 - birth certificate

 - social security number

Need Help Completing the Form?


UB HR Benefits

State Benefit Services

phone: 716-645-7777

Email: ub-hr-benefits@stpatrickshosp.com

Form Facts

Form Type: Downloadable, PDF document


Updated:2020欧洲杯体育直播投注 December 2019

Owner: State of New York Department of Civil Service