Benefits Fund Open Enrollment Form - NYSNA Pension Plan and ... - rnbenefits 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your personal information. Clearly print your last name, first name, and middle initial in the designated fields.
3. Enter your street address, apartment number (if applicable), date of birth, city, state, and ZIP code accurately.
4. Provide your home telephone number and email address. Select your gender by checking the appropriate box.
5. Fill in your employer's name, employment date, position title, and work status (full-time, part-time, or per diem).
6. List your dependents by entering their names and dates of birth. Include details for your spouse and children as required.
7. Review the important notice section carefully before signing. Ensure all information is accurate to avoid any issues.
8. Finally, sign and date the form to complete it before submitting it to the Fund office.

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