Ps 404 pe form 2025

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4.6 out of 5

43 votes

The document is a New York State Health Insurance Transaction Form (PS-404 PE) for employees, detailing instructions for completing the form to request health insurance coverage changes, enrollments, or cancellations. It includes sections for employee information, dependent details, previous coverage information, and options for health plan selection. Additionally, it outlines the process for continuing coverage during leave or retirement and emphasizes the importance of providing accurate information to avoid penalties.

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Click ‘Get Form’ to open the ps 404 pe form in our editor.
Begin by filling out the Employee Information section. Enter your First Name, Middle Initial, Last Name, Social Security Number, Sex, Date of Birth, and contact details including your Street Address, City, State, and Zip Code.
Indicate your Marital Status by checking the appropriate box. If applicable, specify if you are covered under Medicare.
In the Request(s) section, select whether you want to enroll individually or as a family. Choose between Empire Plan or HMO and provide any necessary codes.
If you have dependents to add or change coverage for, complete the Dependent Information section. Use additional sheets if necessary.
Review all entered information for accuracy before submitting. Ensure that any required attachments are included.

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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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