Nys form new york 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Employee Information section. Enter your First Name, Last Name, Middle Initial, Social Security Number, Sex, Street Address, City, State, Zip Code, Telephone Number, and Date of Birth.
3. Indicate your Marital Status and whether you are covered under Medicare. If any information is new, check 'Yes' or 'No' as applicable.
4. In the Enter Request(s) Below section, select your desired medical coverage options such as enrollment type (Individual or Family) and specify the plan (Empire Plan or HMO).
5. If adding dependents, provide their information in the Dependent Information section. Check whether you are adding (A), deleting (D), or changing (C) coverage for each dependent.
6. Complete the Previous Coverage Information if applicable by providing details about any prior health insurance plans.
7. Finally, review all entries for accuracy before signing and dating the authorization at the bottom of the form.

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