City of ny health benefits 2026

1. Click ‘Get Form’ to open the city of NY health benefits application/change form in the editor.
2. Begin by selecting your status as either an Employee, Retiree, or Line of Duty Survivor in Section A. Ensure you check the appropriate box.
3. In Section D, provide your personal information including your last name, first name, social security number, and contact details. Make sure all information is printed clearly.
4. If applicable, complete Section E for spouse/domestic partner details. Include their information only if they are to be covered under your plan.
5. List all eligible dependent children in Section F. Indicate whether you are adding or dropping coverage for each child.
6. Select your desired health plan in Section G and indicate if you want optional benefits by checking 'Yes' or 'No'.
7. Finally, sign and date the form in Section I to authorize the changes requested before submitting it to your agency’s payroll or personnel office.

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