City of new york health benefits program 2026

1. Click ‘Get Form’ to open the Health Benefits Program Application/Change Form in the editor.
2. Begin by selecting your status as either an Employee, Retiree, or Line of Duty Survivor in Section A. Make sure to check the appropriate box.
3. In Section B, indicate any changes regarding your spouse or domestic partner. If applicable, provide necessary documentation such as a death certificate or divorce decree.
4. Complete Section D with your personal information including your last name, first name, Social Security number, and contact details. Ensure all fields are filled clearly.
5. If you have dependents, fill out Section F with their details and specify if you are adding or dropping coverage for each dependent.
6. Review Sections G and H for health plan selection and optional benefits. Make sure to check the boxes that apply to you.
7. Finally, sign and date the form in Section I to authorize your application or changes before submitting it through your agency’s payroll office.

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