NYSHIP Health Benefits Opt-Out Election (PS-409)

During scheduled, announced periods, employees complete this form and the change form  (PS-404) to opt out of NYSHIP health insurance.

Employees represented by GSEU and UUP are not eligible to opt out of NYSHIP Health Insurance.

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NYSHIP Change or Enrollment Form (PS-404)
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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
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Townsend Hall
205 Hayes Road
Buffalo, NY 14214

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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:

Updated: November 2014

Owner: Human Resources