NYSHIP Health Insurance Enrollment or Change Form (PS-404)

State employees enroll or submit changes for NYSHIP health insurance.

Download the Form

Download the NYSHIP Health Insurance Enrollment or Change Form (PS-404)
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Completing the PDF Form

  1. Read through all pages of the document to find specific instructions, if any
  2. Enter requested information into the form
  3. Print the form
  4. Get required signatures
  5. Scan a copy of the signed form for your records
  6. Send the original, completed, signed form to:         

Human Resources
120 Crofts Hall
North Campus

Read About Enrolling and Managing My State Benefits

To enroll family members include copies of:

For Spouse

 - Marriage Certificate

 - Birth Certificate

 - Social Security Number

 - If married more than 1 year proof of financial interdependance

For Children

 - Birth certificate

 - Social Security Number

Need Help Completing the Form?

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UB HR Benefits

State Benefit Services

Phone: 716-645-7777

Email: ub-hr-benefits@buffalo.edu

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: December 2019

Owner: State of New York Department of Civil Service