1. PLEASE SUBMIT THIS FORM WITH EACH REMITTANCE. 

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

3. WRITE YOUR ID NUMBER ON THE FACE 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 F.I. M.I. 
No. and Street Address 
City State ZIP Code 
Date: 

TOTAL AMOUNT REMITTED:  

FOR OFFICE USE ONLY  
Receipt Number  
Amount Received  Date Received