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.
For the best experience in completing this form use a non-mobile device.
120 Crofts Hall
Form Type: Downloadable, PDF document
Requirements: Adobe Reader
Updated: May 2009
Owner: New York State Department of Civil Service