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Click ‘Get Form’ to open the PS-404 in the editor.
Begin by filling out the Employee Information section (Boxes 1-10). Enter your last name, first name, social security number, sex, and addresses. Ensure all fields are completed accurately.
In the Elect or Decline Coverage section (Box 11), choose your coverage options. Select between Pre-Tax or After-Tax deductions and indicate whether you want Individual or Family Enrollment.
If applicable, provide details for any changes in coverage in Box 12. Indicate if you are changing from Individual to Family coverage or vice versa, and specify any qualifying events.
Complete the Dependent Information section (Box 13) if you are adding or changing dependents. Fill in all required details including names and social security numbers.
Finally, sign and date the form in the Authorization section to confirm your selections before submitting.

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See more ps 404 versions

We've got more versions of the ps 404 form. Select the right ps 404 version from the list and start editing it straight away!

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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