Ps 404 2025

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The document is a Health Insurance Transaction Form (PS-404) for New York State and Participating Employers' employees, detailing the process for enrolling in or changing health insurance coverage. It includes sections for employee information, options to elect or decline coverage, changes to existing coverage, and dependent information. The form also outlines the Pre-Tax Contribution Program and provides instructions for submitting additional required documentation.

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Click ‘Get Form’ to open the PS-404 in the editor.
Begin by filling out the Employee Information section (Boxes 1-11). Provide your last name, first name, social security number, sex, and contact details. Ensure accuracy as this information is crucial for processing your request.
In the Elect or Decline Coverage section (Box 12), select your preferred coverage options. You can choose between Pre-Tax and After-Tax deductions for medical coverage. Make sure to check the appropriate boxes for individual or family enrollment.
If you need to change or cancel existing coverage (Box 13), indicate the reason and provide any necessary details regarding qualifying events such as marriage or divorce.
Complete the Dependent Information section (Box 14) if enrolling dependents. Check whether you are adding, deleting, or changing a dependent's information and provide their details.
Finally, ensure you sign and date the form in the Authorization section to validate your submission.

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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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