PS-452 Application for Waiver of Premium - cs ny 2026

Get Form
PS-452 Application for Waiver of Premium - cs ny Preview on Page 1
See details
4.9 out of 5
42 votes
The document is an application form (PS-452) for a waiver of health insurance premium contributions due to total disability, issued by the New York State Department of Civil Service. It outlines the eligibility criteria, including that enrollees on Family Medical Leave can apply, while those receiving short-term disability benefits cannot. The form requires completion by both the enrollee and their employing agency, as well as an attending physician's statement regarding the disability. It emphasizes confidentiality and provides contact information for further inquiries.
DocHub Reviews
44 reviews
DocHub Reviews
23 ratings
15,005
10,000,000+
303
100,000+ users

Here's how it works

01. Edit your form online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out PS-452 Application for Waiver of Premium - cs ny with our platform

Form edit decoration
9.5
Ease of Setup
DocHub User Ratings on G2
9.0
Ease of Use
DocHub User Ratings on G2
  1. Click ‘Get Form’ to open the PS-452 Application for Waiver of Premium in the editor.
  2. Begin by completing Part A. Fill in your name, health insurance ID number, date of birth, home address, and telephone number. Ensure all information is accurate.
  3. Next, proceed to Part B, which must be completed by your employing agency. This includes details such as the effective date of leave without pay status and health insurance coverage type.
  4. Leave Part C blank; this section will be filled out by United Health Care later.
  5. In Part D, your attending physician will need to provide their information and answer specific questions regarding your disability. Make sure they complete this section after Parts A and B are finalized.
  6. Once all parts are completed, save your document and send it to United HealthCare at the provided address.

Start using our platform today to easily fill out your PS-452 Application for Waiver of Premium for free!

Fill out PS-452 Application for Waiver of Premium - cs ny online
It's free
Start now
be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.
Contact us
A waiver of premium rider is an insurance policy clause that waives premium payments if the policyholder becomes critically ill, seriously injured, or physically impaired. Other stipulations may apply, such as meeting specific health and age requirements.
Policyholders may qualify for the waiver of premium rider if they become unable to work or cannot work in a traditional capacity any longer due to: Severe injury. Physical Impairment or. Critical illness.
Cost. The average waiver of premium can typically add $10 to $50 per month to a policys cost. That amount can vary based on your age, health, and coverage amount.
Whether a Waiver of Premium Rider is worth it depends on your circumstances, financial goals, and risk tolerance. It can be a valuable addition for some individuals, but the extra cost may not be justified for others.
What is life waiver of premium benefit? If an member is unable to continue to work due to illness of injury, and satisfies the definition of disability while insured, Canada Life will waive the life insurance premiums for themselves and their dependants throughout the benefit period.

Related Searches

Ps 452 application for waiver of premium cs ny pdf Ps 452 application for waiver of premium cs ny sample Ps 452 application for waiver of premium cs ny online Ps 452 application for waiver of premium cs ny form Ps 452 application for waiver of premium cs ny 2022

Security and compliance

At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.

Learn more

Related links

EMPLOYEE BENEFITS DIVISION Eligibility for a Waiver of

Instructions for Completing the PS-452 Application for Waiver of Empire Plan Premium I hereby apply for a waiver of premium under the New York State

Learn more
Phillips 66

the application process, which can be expensive and time consuming. In addition, there can be delays associated with notice and comment periods and the.

Learn more
2025 - general information book - CS.NY.gov

How to apply for a waiver of premium. To apply for a waiver of premium, obtain the Application for Waiver of Empire Plan Premium (PS-452) from your HBA or

Learn more

Try more PDF tools

Edit & Annotate
Edit PDF
Add Fillable Fields
Create PDF
Insert and Merge
Add Page Numbers
Rotate Pages
Delete Pages
Convert
Word to PDF
TXT to PDF
HTML to PDF
CSV to PDF
PPT to PDF
RTF to PDF
JPG/JPEG to PDF
PNG to PDF
Collaborate & Share
Add Comments
Fax
PDF Status
Sign & Send
Sign a PDF
Send for Signing
Protect PDF
Set PDF password
Readable PDF
Certify PDF
PDF Audit Trail
Others
Search for PDF
Export
Download
Flatten Fields
Print out
If you believe that this page should be taken down, please follow our DMCA take down process here
support@dochub.com
17 Station St., Ste. 303 Brookline, MA 02445
Google Play App Store
© 2026 DocHub, LLC
All Rights Reserved.
Products
PDF Editor
Forms & Templates
Sign Documents
Server Status
Pricing
Forms Library
Features
Functions
Company
About
Terms of Service
Privacy Notice
Legal Hub
E-Signature Compliance
Support
Release Notes
Bug Bounty Program
Resources
Blog
DocHub Mobile App
pdfFiller
US Legal Forms
SignNow
altaFlow
Instapage
What's New
New
DocHub v6.6.0 - @mentions, AI assistant and more
Contact us
support@dochub.com
17 Station St., Ste. 303 Brookline, MA 02445
Google Play App Store
© 2026 DocHub, LLC
All Rights Reserved.