City of new york health benefits application fillable 2012 form-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting your status as either an Employee or Retiree. Check the appropriate box at the top of the form.
3. In Section A, indicate your reason for submission by checking one or more boxes. If applicable, enter the change date next to your selection.
4. 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.
5. Complete Section E with your spouse/domestic partner's information if applicable. Indicate whether they will be covered under your health plan.
6. List all eligible dependents in Section F, ensuring you provide their birth dates and Social Security Numbers where required.
7. In Section G, write the full name of your requested health plan and specify if you want optional benefits.
8. Finally, sign and date the form in Section H or I as required before submitting it to the designated address.

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