STATE OF NEW YORK 
EMPLOYEE BENEFITS DIVISION 
DEPARTMENT OF CIVIL SERVICE THE STATE CAMPUS 
STATE SERVICE SICK LEAVE CREDIT PRESERVATION 
ALBANY, NEW YORK 12239 

STATEMENT OF STATE SERVICE AND SICK LEAVE CREDIT PRESERVATIONFOR NEW YORK STATE HEALTH INSURANCE PROGRAM When retiring from New York State employment and covered as a spouse in the New York State Health Insurance Program, you are advised to ask your employing agency to complete this form. 

This provides evidence of your State service and sick leave credit if you wish to obtain New York State health insurance coverage in your own name in the future. 

You must send a copy of this form and a letter requesting health insurance coverage in your own name to the Employee Benefits Division. In your letter, be sure to give your retirement number and list all dependents you want covered, with their dates of birth. 

Please Print Retiree's 					Name Retiree's Social Security Number 

___________________________				_________________________

Sick Leave Credit: Days  X Rate $ = Total $ Nearest Tenth Nearest Cent Nearest 	Cent 


Negotiating Unit at Retirement: 

Name 									Numeric Code 
___________________________				_________________________


NYS Administered Retirement System: 
	
Name 									Registration Number 
___________________________				_________________________


Dates of Service: 

Current Agency  						Agency Code  
___________________________				_________________________


Current Coverage:  

Please Print Enrollee's Name  			Enrollee's Social Security Number 
___________________________				_________________________


Signature of Agency Health Benefits Administrator Date List all previous State, participating Employer and/or Participating Agency service if the above is less than 10 years (attach additional sheet if necessary). 


Former Agency  					Agency Code  				Dates of Service  
___________________________		_________________________	______________________



You (the retiring spouse) must keep this completed form as documentation of your State service and sick leave credit.