Health Benefits Application Health Benefits Program 40 Rector Street 3rd Floor New York, NY 10006 (212) 5130470 TTY/TDD: (212) 3067753 www 2026

1. Click ‘Get Form’ to open the Health Benefits Application in our editor.
2. Begin by selecting your status as either an Employee, Retiree, or Line of Duty Survivor in Section A. Make sure to check the appropriate box.
3. In Section D, fill in your personal information including Last Name, First Name, Social Security Number, and Date of Birth. Ensure all details are accurate.
4. If applicable, complete Section E for Spouse/Domestic Partner information. Provide their details only if they are to be covered under your plan.
5. List all eligible dependent children in Section F. Indicate whether you are adding or dropping coverage for each child.
6. In Section G, write the full name of the health plan you wish to select. If you want optional benefits, indicate this clearly.
7. Finally, sign and date the form in Section I to authorize your application or changes before submitting it through our platform.

Start filling out your Health Benefits Application today using our platform for a seamless experience!