Form ps 404 2014-2026

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The document is the NYS Health Insurance Transaction Form (PS-404) issued by the New York State Department of Civil Service. It provides instructions for employees to complete their health insurance enrollment, changes, or cancellations regarding medical, dental, and vision coverage. The form requires personal information, options for individual or family coverage, and details on dependent information. It also includes sections for annual option transfers, leave without pay, retirement decisions, and necessary documentation for processing transactions.

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Click ‘Get Form’ to open the PS-404 in the editor.
Begin by filling out your personal information in boxes 1-9. Ensure accuracy, especially for your Social Security Number and Date of Birth.
In box 10, select your desired coverage options. You can choose individual or family coverage for medical, dental, and vision plans. Check the appropriate boxes based on your selections.
If applicable, complete box 11 for annual option transfer requests during the designated period or due to qualifying events.
For leave without pay or retirement status, fill out box 12 to indicate your preferences regarding health coverage continuation.
Finally, review all entries for accuracy before signing and dating the form at the bottom.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (221 Votes)
2019	4.3 Satisfied (52 Votes)
2017	4.2 Satisfied (78 Votes)
2017	4.4 Satisfied (129 Votes)
2014	4.3 Satisfied (76 Votes)
2011	4.8 Satisfied (49 Votes)
2007	4.6 Satisfied (43 Votes)
2006	4 Satisfied (54 Votes)
2001	4.1 Satisfied (28 Votes)

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What is a PS form 2548?

New employee training must be recorded on PS Form 2548, Individual Training Record. The training agent (the LDDS or the employees job instructor) and the immediate supervisor complete PS Form 2548. The LDDS retains the form at a central location, which the training supervisor or manager determines.

What is a PS 404 form?

Use to sign up for health insurance or make changes to your existing benefits.

What is error 404 when submitting forms?

A 404 error occurs when a page cant be found on the server. In FastField, this usually happens when youre trying to submit a form thats been deleted from your account.

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What is a PS form 3883?

United States Postal Service Firm Delivery Receipt for Accountable and Bulk Delivery Mail.

Form ps 404 2014-2026

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