Health Insurance Forms
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- Civil Service Employee Benefit Forms Online
- Dependent COBRA Request Sample Letter (use AFTER notifying local Benefits Coordinator) - Word 23 KB
- Empire Plan Out-of Network Claim Form - PDF 427 KB
- PS-404 Health Insurance Transaction Form - PDF 294 KB
- PS-404* Opt Out Health Insurance Transaction Form (*use ONLY if eligible to Opt Out) - PDF 327 KB
- PS-404G Graduate Student Health Insurance Transaction Form - PDF 21 KB
- PS-405 Dual Annuitant Sick Leave Credit Election Form - PDF 23 KB
- PS-406.2 Deferred Health Insurance for Retirees Form - PDF 21 KB
- PS-409 Opt Out Attestation Form (Use with PS-404*) - PDF 113 KB
- PS-410 Save Credit Preservation Form - PDF 14 KB
- PS-425 Information Regarding Domestic Partner Insurance - PDF 27 KB
- PS-425.1 Enrolling a Domestic Partner/required forms - PDF 40 KB
- PS-425.3 Dependent Tax Affidavit for Domestic Partners - PDF 27 KB
- PS-425.4 Termination of Domestic Partnership - PDF 22 KB
- PS-431 Insurance Information for Employees on Leave Without Pay - PDF 24 KB
- PS-452 Waiver of Premium Application - PDF 30 KB
- PS-457 Statement of Dependence - PDF 37 KB
- PS-459 Application for Reduced Maximum Out-of-Pocket Co-insurance Expense - PDF 21 KB
- PS-600 Coordination of Benefits Notice - PDF 17 KB