EMPLOYEE BENEFITS DIVISION 


STATE OF NEW YORK DEPARTMENT OF CIVIL SERVICE
THE STATE CAMPUS DEFERRED HEALTH INSURANCE COVERAGE FOR RETIREES 
ALBANY, NEW YORK 12239 

ENROLLMENT FORM FOR EMPLOYEES ELIGIBLE TO DEFERHEALTH INSURANCE COVERAGE AND SICK LEAVE CREDITCALCULATION INDEFINITELY IN RETIREMENT

Enrollees who have health insurance coverage through their post-retirement employment, or through their spouse's employer,are eligible to defer indefinitely (UUP: up to 5 years) the activation of their New York State Health Insurance Program (NYSHIP) coverage as retirees. Retirees use their sick leave credit to reduce their health insurance premiums. If you defer your NYSHIP coverage when you notify EBD to activate your coverage, your sick leave credit will be calculated when you are older and will have a greater dollar value than if it were calculated immediately at retirement. You will not have to pay NYSHIP premiums while your coverage is deferred. If you die while your coverage is deferred, your spouse and/or eligible dependents may transfer back to NYSHIP. Coverage for the eligible survivors would begin on the day following your death. Eligible survivor(s) who wish to enroll should do so as soon as possible to avoid retroactive premium payments.

If you wish to defer your retiree health insurance coverage, furnish proof to your agency health benefits administrator that you have coverage through post-retirement employment, or through your spouse's health care plan, and complete the form below. Keep a copy of the completed form for your records.

ENROLLMENT FORM FOR EMPLOYEES ELIGIBLE TO DEFER HEALTH INSURANCECOVERAGE AND SICK LEAVE CREDIT CALCULATION INDEFINITELY IN RETIREMENT

I,  (Please print name in this space)___________ (Social Security Number) ___________ have read the information provided to me about Deferred Health Insurance Coverage for Retirees. I wish to defer my New York State Health Insurance Program coverage, understanding that I may defer only once. My last day on the payroll is . (Month Day Year)_________

I understand that if I pre-decease my spouse and/or other eligible dependent(s) while coverage is deferred, they may transfer back to the State Health Insurance Program. Their coverage would begin on the day following my death. My eligible survivor(s) should send a written request for enrollment to the Employee Benefits Division Operations�Deferred Health Insurance Coverage Unit, at the above address as soon as possible after my death, to avoid retroactive premium payments. 

I understand that I may reactivate my enrollment in the State Health Insurance Program at any time, by writing to the Employee Benefits Division Operations�Deferred Health Insurance Coverage Unit, at the above address. 


Proof of my continued coverage in my spouse's health care plan is attached. 

Proof of my coverage through post-retirement employment is attached. 



Signature of Enrollee 										Date 

___________________________									__________

Signature of Agency Health Benefits Administrator 			Date 

___________________________									__________