State of New York Department of Civil Service Employee Benefits Division Albany, NY 12239 EMPLOYEE B 2026

1. Click ‘Get Form’ to open the document in the editor.
2. Begin by filling out the 'Employing Agency Section'. Enter your name, date of hire, agency contact name, and agency code. Ensure all details are accurate for proper processing.
3. Next, complete the 'Employee Section'. Indicate your understanding of the enrollment opportunity and provide your signature along with your New York State ID and Social Security Number.
4. Review the 'Open Enrollment Expiration Date' section. Make sure to note that this period lasts 60 calendar days from your date of hire or eligibility.
5. Finally, ensure all fields are filled correctly before saving or exporting the completed form. You can easily share it directly from our platform.

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