Enrollment form for young adult coverage in NYSHIP health insurance.
120 Crofts Hall
1. Attach documentation to verify eligibility of young adult.
2. Make check payable to
Employee Insurance Pending Account
New York State Department of Civil Service
Employee Benefits Division - YAO
Albany, New York 12239
Form Type: Downloadable, PDF document
Requirements: Adobe Reader
Updated: December 2012
Owner: New York State Department of Civil Service