Ps 404 2025

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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, change existing coverage, and provide dependent information. The form also outlines the Pre-Tax Contribution Program and requirements for submitting proofs of eligibility. Additionally, it emphasizes the importance of accurate information and signatures for processing requests.

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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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