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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  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

Need Help Completing the Form?

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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: May 2009

Owner: New York State Department of Civil Service