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.

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  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?

Send email, phone or submit a question

Lissa Jasinowski

Retirement Administrator

State Benefit Services

Phone: (716) 645-4488

Email: lmt22@buffalo.edu

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Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: May 2009

Owner: New York State Department of Civil Service