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City of new york health benefits application fillable 2012 form-2026
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How to use or fill out City of New York Health Benefits Application Fillable 2012 Form
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- Click ‘Get Form’ to open it in the editor.
- Begin by selecting your status as either an Employee or Retiree. Check the appropriate box at the top of the form.
- In Section A, indicate your reason for submission by checking one or more boxes. If applicable, enter the change date next to your selection.
- Proceed to Section D and fill in your personal information including Last Name, First Name, Social Security Number, and Date of Birth. Ensure all details are accurate.
- Complete Section E with your spouse/domestic partner's information if applicable. Indicate whether they will be covered under your health plan.
- List all eligible dependents in Section F, ensuring you provide their birth dates and Social Security Numbers where required.
- In Section G, write the full name of your requested health plan and specify if you want optional benefits.
- Finally, sign and date the form in Section H or I as required before submitting it to the designated address.
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