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B. Voluntarily Cancel Coverage Vision 14 Qualifying Event NYS Department of Civil Service Albany NY 12239 Health Insurance Transaction Form Page 2 - PS-404 9/17 DEPENDENT INFORMATION Must be provided when choosing to enroll or opt-out of NYSHIP family coverage use additional sheets if necessary Check One A Add D Delete or C Change Check all that apply M Medical D Dental and V Vision A D C Relationship Address if different Sex M V Number ENTER ANNUAL OPTION TRANSFER REQUEST S BELOW Change NYSHIP ...

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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)
2001	4.1 Satisfied (28 Votes)

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