Ps 404 2025

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4.4 out of 5

129 votes

The document is the NYS Health Insurance Transaction Form (PS-404) used by employees to manage their health insurance coverage options, including enrollment, changes, and cancellations. It requires personal and dependent information, allows for selection of medical, dental, and vision plans, and provides instructions for opting out or changing coverage. Additionally, it outlines procedures for employees on leave or retiring and emphasizes the importance of providing accurate information to avoid penalties.

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Click ‘Get Form’ to open the PS-404 in the editor.
Begin by filling out the Employee Information section (Boxes 1-9). Enter your first and last name, Social Security Number, sex, date of birth, and contact details. Ensure accuracy as this information is crucial for processing.
In Box 10, provide Dependent Information if applicable. Check the appropriate boxes to add or delete dependents and fill in their details including relationship and date of birth.
For New or Newly Eligible Employees (Box 11), select your coverage options. You can choose between individual or family enrollment for medical, dental, and vision plans. Make sure to indicate your Pre-Tax or Post-Tax status.
If you need to change or cancel coverage (Box 12), check the relevant box and provide details about the qualifying event that necessitates this change.
Complete Box 14 regarding Leave Without Pay and Retirement Status if applicable. Indicate whether you wish to continue coverage during your leave.
Finally, sign and date the form in the Authorization section to confirm that all provided information is accurate.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (221 Votes)
2019	4.3 Satisfied (52 Votes)
2017	4.2 Satisfied (78 Votes)
2017	4.4 Satisfied (129 Votes)
2014	4.3 Satisfied (76 Votes)
2011	4.8 Satisfied (49 Votes)
2007	4.6 Satisfied (43 Votes)
2006	4 Satisfied (54 Votes)
2001	4.1 Satisfied (28 Votes)

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