Health Insurance Forms
The following forms are in Microsoft Word and/or PDF format and can be downloaded and printed for your convenience. Download free Adobe Acrobat Reader to view forms in Portable Document Format (PDF).
- Civil Service Employee Benefit Forms Online
- Empire Plan Out-of Network Claim Form
- PS-404 Health Insurance Transaction Form- PDF
- PS-404G Graduate Student Health Insurance Transaction Form - PDF
- PS-405 Dual Annuitant Sick Leave Credit Election Form - PDF
- PS-406.2 Deferred Health Insurance for Retirees Form - PDF
- PS-409 Opt Out Attestation Form (Use with PS-404) - PDF
- PS-410 Sick Leave Credit Preservation Form - PDF
- PS-425 Information Regarding Domestic Partner Insurance - PDF
- PS-425.1 Enrolling a Domestic Partner/required forms - PDF
- PS-425.3 Dependent Tax Affidavit for Domestic Partners - PDF
- PS-425.4 Termination of Domestic Partnership - PDF
- PS-431 Insurance Information for Employees on Leave Without Pay - PDF
- Ps-451 Statement of Disability Form - PDF
- PS-452 Waiver of Premium Application - PDF
- PS-452.1 Waiver of Premium Instructions - PDF
- PS-457 Statement of Dependence - PDF
- Request for Coverage Under the Young Adult Option Form - PDF