Health Insurance Forms
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- Civil Service Employee Benefit Forms Online
- Health Insurance Transaction Form (PS-404) - PDF 29 KB
- Graduate Student Health Insurance Transaction Form (PS-404G) - PDF 21 KB
- Empire Plan Out-of Network Claim Form - PDF 427 KB
- Dual Annuitant Sick Leave Credit Election Form (PS-405) - PDF 23 KB
- Deferred Health Insurance for Retirees Form (PS-406.2) - PDF 21 KB
- Sick Leave Credit Preservation Form (PS-410) - PDF 14 KB
- Information regarding Domestic Partner insurance (PS-425) - PDF 27 KB
- Enrolling a Domestic Partner/required forms (PS-425.1) - PDF 40 KB
- Dependent Tax Affidavit for Domestic Partners (PS-425.3) - PDF 27 KB
- Termination of Domestic Partnership (PS-425.4) - PDF 22 KB
- Insurance Information for Employees on Leave Without Pay (PS-431) - PDF 24 KB
- LWOP Health Insurance Remittance Notice (PS-436.1) - PDF 12 KB
- Family LWOP Health Insurance Remittance Notice (PS-436.2) - PDF 8 KB
- Waiver of Premium Application (PS-452) - PDF 30 KB
- Statement of Dependence (PS-457) - PDF 37 KB
- Application for a Reduced Maximum Out-of-Pocket Co-insurance Expense (PS-459) - PDF 21 KB
- Coordination of Benefits Notice (PS-600) - PDF 17 KB
- Dependent COBRA Request Sample Letter (use AFTER notifying local Benefits Coordinator) - Word 23 KB