NYSHIP Health Benefits Opt-Out Election (PS-409)

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 and UUP are not eligible to opt out of NYSHIP Health Insurance.

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Completing the PDF Form

  1. Read through all pages of the document to find specific instructions, if any
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  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

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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: November 2014

Owner: Human Resources