EMPLOYEE INFORMATION (All employees must complete)  



1. Last Name 			First Name 			MI  

2. Social Security Number 
 
3. Sex 			Male/Female  

4. Street Address		 City 		State 		Zip  

5. Date of Birth  

6. Telephone Numbers Home ( )   Work ( )  

7. Work location and address  

8. Marital Status Single Married Widowed Divorced   

9. Covered under Medicare? 		Yes No     
	Spouse/Domestic 		Yes No
	Partner/Dependent Child      	Yes No  

10.      ENTER REQUEST(S) BELOW  

A. Request New Enrollment Individual Family (Complete D)  Decline Coverage (Process WAV/BEN transaction)  Voluntarily 	Cancel Coverage (Qualifying Event: )

B.  Elect/Change Pre-Tax Status for Premium deduction  __Pre-Tax  __Post-Tax
If you chose Pre-Tax initial here to indicate that you have read the Pre-Tax Contribution memorandum. ______  

C.  Change Coverage____    Date of Event____ Change to INDIVIDUAL I voluntarily cancel coverage for my dependents I voluntarily cancel coverage for my domestic partner Change to FAMILY (Complete D) Marriage Domestic Partner acquired/first eligible First dependent child acquired Arrival of eligible dependent in United States Request coverage for dependents not previously      covered Newborn Previous coverage terminated (Complete Section 11) Other Only dependent died Only dependent married Divorce Only dependent disqualified by age Termination of domestic partnership (Attach Completed PS-425.4) Other  

D. DEPENDENT INFORMATION (use additional sheets if necessary) Check One: A (Add),  D (Delete) or C (Change) 


AGENCY/EBD USE ONLY  

NYS Department of Civil Service Health Insurance Transaction Form The State Campus Graduate Student Employee Union Albany, NY 12239 Student Employee Health Plan PS-404G (12/01L) 


11.   PREVIOUS COVERAGE INFORMATION  

Complete this section if you are requesting new enrollment or a change to family coverage because you or your dependent�s previous coverage was terminated (regardless of whether coverage was previously provided under NYSHIP or another health insurance plan) and you are requesting to have late enrollment of your benefits waived  (attach proof: i.e. insurance bill or letter confirming former coverage and the end date of such coverage).  

Previous ID Number  		Date 		Coverage Terminated 
		
Enrollee�s Name Under Which Previously Covered 
Last 		First 		Middle 			Initial  


12.	REQUEST FOR GSEU BENEFIT CARD (Student Employee Health Card) ONLY FOR: 

ENROLLEE___ DUPLICATE__ CARD ENROLLEE AND ALL DEPENDENTS____ (Previously issued card remains valid.) REPLACEMENT CARD___

INDIVIDUAL DEPENDENT (Previously issued card(s), lost or stolen, become invalid.)

Personal Privacy Protection Law NotificationThis information you provide on this application is requested in accordance with Section 163 of the New York State Civil Service Lawfor the principal purpose of enabling the NYS Department of Civil Service to process your request concerning health insurance coverage.This information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e)and (f). Failure to provide the information requested may interfere with our ability to comply with your request. This information will bemaintained by the Director of the Employee Benefits Division, NYS Department of Civil Service, The State Campus, Albany, NY 12239.For information concerning the Personal Protection Law, call (518) 457-9375. For information related to the Health Insurance Program,contact your Agency Health Benefits Administrator. If, after calling your Agency Health Benefits Administrator, you need moreinformation, please call  (518) 457-5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 3:00 p.m.


AUTHORIZATION  

I have read the Pre-Tax Contribution Program memorandum and have made my selection on Page 1 of this document, if applicable. I understand that if I voluntarily decline or cancel my coverage, I may subject myself and/or my dependents to waiting periods if I decide to enroll at a later date, and I may be forfeiting the right to COBRA Continuation Coverage rights for myself and/or my dependents. I certify that the information I have supplied is true and correct. I understand that my failure to provide required proof(s) within 30 days of the end of the initial or annual enrollment periods or within 30 days of a qualifying event may delay the availability of benefits for me or any dependent for whom I fail to provide such proof. Any person who makes a material misstatement of fact or conceals any pertinent information shall be guilty of a crime, conviction of which may lead to substantial monetary penalties and/or imprisonment, as well as an order for reimbursement of claims. I hereby authorize deduction from my salary of the amount required, if any, for insurance indicated above. This authorization shall be in effect until I revoke it in writing.

  
Employee�s Signature (Required)  	__________________________________

Signature Date (Required)		__________________________________