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Click ‘Get Form’ to open the NYC Health Benefits Report Inquiry Form in the editor.
Begin by selecting your status as either 'Employee' or 'Retiree' and indicate if this is a second request. Fill in the date of submission.
Choose your health plan from the provided options, such as AETNA HMO or CIGNA HEALTHCARE. If your plan is not listed, specify it in the 'OTHER' field.
In the 'REASON(S) FOR SUBMISSION' section, check one or more boxes that apply to your situation, such as status changes or requests for refunds.
Complete the EMPLOYEE INFORMATION section with your last name, first name, middle initial, social security number, and home address.
Fill out your EMPLOYEE PAYROLL INFORMATION including agency code and job sequence number. Select your pay period frequency.
If applicable, provide any additional explanations in the EXPLANATION INQUIRY section before submitting the form.

Start filling out your NYC Health Benefits Report Inquiry Form online for free today!

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