Ps 404 2026

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4.3 out of 5

52 votes

The document is a Health Insurance Transaction Form (PS-404) for New York State and Participating Employer employees, detailing the process for enrolling in or changing health insurance coverage. It includes sections for employee information, options to elect or decline coverage, and procedures for changing or canceling existing coverage. The form also requires dependent information when applicable and emphasizes the importance of providing accurate details to avoid delays in benefits. Additionally, it outlines the Pre-Tax Contribution Program and provides instructions for submitting the form.

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Click ‘Get Form’ to open the PS-404 in the editor.
Begin by filling out the Employee Information section (Boxes 1-10). Include your last name, first name, social security number, date of birth, and contact details. Ensure accuracy as this information is crucial for processing your request.
In Boxes 11(A-B), elect or decline coverage. Choose between Pre-Tax and After-Tax options for premium deductions and select your desired NYSHIP coverage option—Individual or Family Enrollment.
If you need to change or cancel existing coverage, complete Box 12. Indicate whether you are changing from Individual to Family coverage or vice versa, and provide the relevant qualifying event date.
For dependent information (Box 13), check whether you are adding, deleting, or changing a dependent's information. Fill in all required details including their relationship and social security number.
Finally, review all entries for accuracy before signing and dating the form in the Authorization section.

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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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Ps 404 2026

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