EMPLOYEE BENEFITS DIVISION 
STATE OF NEW YORKDEPARTMENT OF CIVIL SERVICETHE STATE CAMPUS

LEAVE WITHOUT PAY HEALTH INSURANCE REMITTANCE NOTICE ALBANY, NEW YORK 12239 
PS-436.1 (6/00)(w) 



1. PLEASE SUBMIT THIS FORM WITH EACH REMITTANCE. 

2. MAKE REMITTANCE PAYABLE TO: NYS Employees' Health Insurance Pending Account 

3. WRITE YOUR SOCIAL SECURITY NUMBER IN THE UPPER LEFT CORNER OF YOUR CHECK. 

4. MAIL PAYMENT TO: NYS Department of Civil Service, Employee Benefits Division, The State Campus, Albany, New York, 12239. 


HEALTH INSURANCE IDENTIFICATION NUMBER 

Last Name (20 -32) F.I. (33) M.I. (34) 

NO PARTIAL PAYMENTS 

No. and Street Address 

City State ZIP Code 

Date: 


TOTAL AMOUNT REMITTED: $