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EMPLOYEE BENEFITS DIVISION State of New York Department of Civil Service Alfred E* Smith State Office Bldg. Request EnrollmentIndividual B. C. Decline Coverage D. For Agency Use Select Empire Plan Option 7 core plus med psych List dependents in section G 8 core only Voluntarily Cancel Coverage E* Name Change F* Process waive benefits transaction Previous Name was Change Coverage Date of Event Change to FAMILY Complete G Change to INDIVIDUAL Marriage Domestic Partner First dependent child acquir ...

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