How to change your health insurance carrier manually

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How to Change Health Carriers

  1. Complete a PS-404 (Health Insurance Transaction Form)

    *Form is available in the Office of Human Resources and on-line (accessible from theForms Center under Human Resources)

    Form link:

How to Complete Forms Required to Change Health Carriers

  1. PS-404

    1. Complete numbers 1-10
    2. On the reverse (or second page) complete number 14
    3. Sign and date under the Authorization section on the reverse (or second) page. All forms must be signed and dated.
    4. Send to the Office of Human Resources

  2. Note: Doctor(s) information may be provided at a later date directly to the carrier.

    **It is highly recommended your form be received by The Office of Human Resources at least two weeks prior to your new policy effective date.

Last Updated 11/13/17

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