NYSHIP Sick Leave Credit Election For Retirement (PS-405)

State employee elects to apply sick leave credit for NYSHIP retiree health insurance.

You must make this one-time choice prior to retirement no later than your last day worked.

 

If you do not make a choice, you will be automatically enrolled in the Single Annuitant option.

Download the Form

Download the NYSHIP Sick Leave Credit Election (PS-405) Form
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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

Need Help Completing the Form?

Lissa Jasinowski.

Lissa Jasinowski

Retirement Administrator

State Benefit Services

Phone: (716) 645-4488

Email: lmt22@buffalo.edu

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: May 2009

Owner: New York State Department of Civil Service