When you retire, you may apply for either: 

	(a) the Full Value Option or; 

	(b) Dual Annuitant Option, where 70 percent of your calculated monthly sick leave credit is applied towards your 		monthly health insurance premium in retirement. 


If you elect the �Full-Value� Option - 
	100 % of your sick leave credit will be used to offset your monthly health insurance premium for as long as you 	are enrolled, until you die. Your sick leave credit will terminate upon your death. 

If you elect the �Dual- Annuitant� Option - 
	70 % of the reduced sick leave credit will be applied towards your monthly health insurance premiums for as long as 	you are enrolled. Upon your death, the same 70% of your sick leave credit will be applied towards the monthly health 	insurance premiums for your enrolled dependent(s), until they lose eligibility. Only dependents enrolled under your 	coverage at the time of your death may receive this benefit. 

Check One: 
	a.  Full-Value Option  Please apply 100 % of my monthly sick leave credit towards my monthly health insurance 			premium. I understand that if I select this option, my sick leave credit will end with my death and will not be 		available to my covered dependent(s).  

	b.  Dual � Annuitant Option  Please apply 70 % of my monthly sick leave credit towards my monthly health 	insurance premium. I understand that if I select this option, my sick leave credit will be used to reduce my health 	insurance premiums during my lifetime, and also to reduce the premium of my covered dependent(s) for the duration of 	their eligibility if I predecease them. If my dependents die before me, I will retain the 70 percent sick leave 	credit.


YOU MUST MAKE THIS ONE-TIME CHOICE BEFORE YOUR LAST DAY ON THE PAYROLL PRIOR TO RETIREMENT.

If you do not make a choice, the �Full-Value Option� - 
	Full Sick Leave Credit (100%) will be applied automatically to your premium. This Full Sick Leave Credit will end 	then you die and it will not be available to covered surviving dependent(s).


I have read the information provided to me regarding Dual Annuitant Sick Leave Credit and have made my selection. I understand that I may not change my selection after I retire.

Signature: 							Date:  

Please Print Name in this Space:  				Social Security Number:  

Signature of Agency Health Benefits Administrator: 		Date:  

Agency Name:  							Agency Code  


Note: 

The State Service Sick Leave Credit Preservation Form (PS-410) verifies State Service Dates and Sick Leave Credit. If your covered spouse is a New York State employee and eligible for health insurance coverage, your spouse should obtain a completed PS-410 from the Health Benefits Administrator upon his or her retirement. This completed form is necessary if your spouse wishes to obtain health insurance in his/her own name at a later date.

Personal Privacy Protection Law Notification: 

This information you provide on this application is requested for the principal	purpose of enabling the Department of Civil Service to process your election concerning the use of sick leave credit to reduce health insurance premiums after retirement. 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 maintain such record. This information will be maintained 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. If you have a question, regarding this form or the health insurance coverage, please call (518) 457-5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 3:00 p.m.

Please make a copy of this signed election for your records.