ࡱ>  Jbjbj *(7R R    !!!8YM!\6 %%%3%/3Q6LD[F[F[F[F[F[F[$]O`j[ 7-/.77j[%3%bo\<<<7dR% %D[<7D[<<W"J[%e_L!8|ZJ0[\0\ZJ`8`[` [ 77<77777j[j[<777\7777`777777777R [:  INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES.EMPLOYEE INFORMATION(All employees must complete)Last Name  FORMTEXT      First Name  FORMTEXT      MI  FORMTEXT      Social Security Number  FORMTEXT XXX-XX-Sex  FORMCHECKBOX  Male  FORMCHECKBOX  FemaleStreet Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip  FORMTEXT      Date of Birth  FORMTEXT      Telephone Numbers Home ( FORMTEXT      )  FORMTEXT       Work ( FORMTEXT      )  FORMTEXT      Work location and address SUNY Brockport 350 New Campus Drive Brockport, NY 14420Marital Status  FORMCHECKBOX  Single FORMCHECKBOX  Married  FORMCHECKBOX  Widowed FORMCHECKBOX  Divorced  FORMCHECKBOX  SeparatedDate Married/Divorced etc.  FORMTEXT       Covered under Medicare? Self  FORMCHECKBOX Yes  FORMCHECKBOX  No Spouse/Domestic Partner  FORMCHECKBOX Yes  FORMCHECKBOX  No ENTER REQUEST(S) BELOW FORMCHECKBOX  Request Enrollment- Individual Medical (10) (Select Empire Plan or HMO)  FORMCHECKBOX Empire Plan  FORMCHECKBOX  HMO* Code  FORMTEXT       Name  FORMTEXT       FORMCHECKBOX  Dental (11) FORMCHECKBOX  Vision (14) FORMCHECKBOX  Request Enrollment- Family (Complete G)Medical (10) (Select Empire Plan or HMO)  FORMCHECKBOX Empire Plan  FORMCHECKBOX  HMO* Code  FORMTEXT       Name  FORMTEXT        FORMCHECKBOX  Dental (11) FORMCHECKBOX  Vision (14) FORMCHECKBOX  Elect Pre-Tax Status for Premium deduction?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, initial here to indicate that you have read the Pre-Tax Contribution memorandum. FORMTEXT       FORMCHECKBOX  Decline Coverage  FORMCHECKBOX Medical (10) FORMCHECKBOX  Dental (11) FORMCHECKBOX  Vision (14) (Process WAV/BEN transaction) FORMCHECKBOX  Voluntarily Cancel Coverage  FORMCHECKBOX Medical (10)Qualifying Event: FORMTEXT       FORMCHECKBOX  Dental (11) FORMCHECKBOX  Vision (14) FORMCHECKBOX  Change Coverage  FORMCHECKBOX Medical (10) FORMCHECKBOX  Dental (11) FORMCHECKBOX  Vision (14) Date of Event:  FORMTEXT         FORMCHECKBOX  Change to FAMILY (Complete G)  FORMCHECKBOX  Marriage  FORMCHECKBOX  Domestic Partner  FORMCHECKBOX  First dependent child acquired  FORMCHECKBOX  Dependent returned to full-time student status  FORMCHECKBOX  Request coverage for dependents not previously covered  FORMCHECKBOX  Newborn  FORMCHECKBOX  Previous coverage terminated (Complete Section 11)  FORMCHECKBOX  Other  FORMTEXT         FORMCHECKBOX  Change to INDIVIDUAL  FORMCHECKBOX  I voluntarily cancel coverage for my dependents  FORMCHECKBOX  I voluntarily cancel coverage for my domestic partner FORMCHECKBOX  Only dependent died  FORMCHECKBOX  Only dependent married  FORMCHECKBOX  Only dependent graduated  FORMCHECKBOX  Divorce  FORMCHECKBOX  Only dependent disqualified by age  FORMCHECKBOX  Termination of domestic partnership (Attach Completed PS-425.4)  FORMCHECKBOX  Other  FORMTEXT       G.  DEPENDENT INFORMATION (use additional sheets if necessary)Check One: A (Add), D (Delete) or C (Change) Check all that apply: M (Medical), D (Dental), and V (Vision) Date of Event  FORMTEXT      Last Name First NameMIRelationshipDate of BirthSexAddress (if different)Social Security Number FORMCHECKBOX  A  FORMCHECKBOX  D  FORMCHECKBOX  C FORMCHECKBOX  M FORMCHECKBOX  D FORMCHECKBOX  V FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  A  FORMCHECKBOX  D  FORMCHECKBOX  C FORMCHECKBOX  M FORMCHECKBOX  D FORMCHECKBOX  V FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMCHECKBOX  A  FORMCHECKBOX  D  FORMCHECKBOX  C FORMCHECKBOX  M FORMCHECKBOX  D FORMCHECKBOX  V FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMCHECKBOX  A  FORMCHECKBOX  D  FORMCHECKBOX  C FORMCHECKBOX  M FORMCHECKBOX  D FORMCHECKBOX  V FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT      10. Continued. ENTER REQUEST(S) BELOWH.  FORMCHECKBOX  Change Medical Benefit PlanChange to:  FORMCHECKBOX  Empire Plan  FORMCHECKBOX  HMO * Code  FORMTEXT       HMO Name  FORMTEXT       I. 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PREVIOUS COVERAGE INFORMATIONIf you were previously covered under NYSHIP or another health insurance plan (attach proof, i.e. insurance bill or letter stating former coverage), please complete this section.Previous ID Number  FORMTEXT      Date Coverage Terminated   FORMTEXT      Enrollee s Name Under Which Previously CoveredLast  FORMTEXT      First  FORMTEXT      Middle Initial  FORMTEXT      12. LEAVE WITHOUT PAY AND RETIREMENT STATUSLEAVE WITHOUT PAY FORMCHECKBOX  I wish to continue coverage while I am on authorized leave. I understand that I will be billed for this coverage. FORMCHECKBOX  Medical  FORMCHECKBOX  Dental  FORMCHECKBOX  Vision FORMCHECKBOX  I do not wish to continue coverage while I am on authorized leave. I wish to resume my coverage upon return to the payroll. FORMCHECKBOX  Medical  FORMCHECKBOX  Dental  FORMCHECKBOX  VisionRETIREMENT FORMCHECKBOX  I understand the requirements for continuing medical insurance coverage as a retiree and wish to continue my coverage. FORMCHECKBOX I understand the requirements for continuing medical insurance coverage as a retiree and wish to defer my coverage. (A completed PS-406.2 must be attached.)13. REQUEST FOR EMPIRE PLAN CARD ONLYFor Health Maintenance Organization (HMO) cards, contact your HMO. FORMCHECKBOX  DUPLICATE CARD (Previously issued card remains valid.)  FORMCHECKBOX  REPLACEMENT CARD (Previously issued card(s), lost or stolen, become invalid.)FOR FORMCHECKBOX  ENROLLEE  FORMCHECKBOX  ENROLLEE AND ALL DEPENDENTS  FORMCHECKBOX  INDIVIDUAL DEPENDENT Name  FORMTEXT       Personal Privacy Protection Law Notification This information you provide on this application is requested in accordance with Section 163 of the New York State Civil Service Law for the principal purpose of enabling the Department of Civil Service to process your request concerning health insurance coverage. This information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e) and (f). Failure to provide the information requested may interfere with our ability to comply with your request. This information will be maintained by the Director of the Employee Benefits Division, NYS Department of Civil Service, The State Campus, Albany, NY 12239. For information concerning the Personal Protection Law, call (518) 457-9375. For information related to the Health Insurance Program, contact your Agency Health Benefits Administrator. If, after calling your Agency Health Benefits Administrator, you need more information, please call (518) 457-5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 3:00 p.m.AUTHORIZATIONI have read the Pre-Tax Contribution Program memorandum and have made my selection on Page 1 of this document, if applicable. I understand that if I voluntarily decline or cancel my coverage, I may subject myself and/or my dependents to waiting periods if I decide to enroll at a later date, and I may be forfeiting the right to such coverage after leaving State service (vest, retirement, etc.). I certify that the information I have supplied is true and correct. I understand that my failure to provide required proof(s) within 28 days (30 days for newborns) may delay the availability of benefits for me or any dependent for whom I fail to provide such proof. Any person who makes a misstatement of fact or conceals any pertinent information, commits a crime which is subject to a $5,000 penalty and the stated value of the claim for each violation. I hereby authorize deduction from my salary or retirement allowance of the amount required, if any, for insurance indicated above. This authorization shall be in effect until I revoke it in writing.Employee s Signature (Required) ________________________________ Signature Date (Required) _________________AGENCY/EBD USE ONLYAction/ReasonDate of EventHire DateDate of 1st Eligibility (PE only)Percentage WorkingAgency CodeNeg. UnitRet. System FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Retirement TierRegistration #Sick Leave InformationDate Entered on NYBEASEffective Date# HoursHourly Rate of Pay FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT      HBA Signature:Date: FORMTEXT           PAGE 2 NYS Department of Civil Service Health Insurance Transaction Form The State Campus, Albany, NY 12239 PS-404 (8/01L) Page 2  Start date: Neg: Accepted by: EMPLOYEE BENEFITS DIVISION State of New York Department of Civil Service The State Campus Albany, NY 12239  EMBED Word.Picture.8  PS-404 (8/01L) NYS HEALTH INSURANCE TRANSACTION FORM ˜&Nvؚښܚ:Fnz}pkd[$$Ifl4D\|N n(` \  +4 laf4$If  !$If֛؛ڛœĜΝН$&(<>Z\^rt̟Ο ڸڭڢڗڌځjchavUj5chavUjbhavUjlahavUj`havUj`havUj `havU hav5CJ hav5havjhavUmHnHujhavUj]havU.ull $$Ifa$kdG^$$Ifl4r|N "n(  2 T +4 laf4$IfœΝn$If $$Ifa$Jkd^_$$Ifl480|n(*  (  +4 laf4npr4}  !$If$Ifpkda$$Ifl4\|T n(    N  +4 laf4 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