During scheduled, announced periods, employees complete this form and the change form (PS-404) to opt out of NYSHIP health insurance.
Employees represented by GSEU are not eligible to opt out of NYSHIP Health Insurance.
For the best experience in completing this form use a non-mobile device.
You may not be able to fill out this PDF form on your mobile device.
120 Crofts Hall
Form Type: Downloadable, PDF document
Requirements: Adobe Reader
Updated: November 2014
Owner: Human Resources