Change in Employment

Change in employment that affects eligibility (for you or your spouse)

1. Complete the NYSHIP Transaction Form or HIP Transaction Form based upon your selection

2. Deduction PRE-TAX Election

3. HEALTH INSURANCE ACKNOWLEDGEMENT

   • Paraprofessionals, please use THIS FORM and attach documentation for when your current coverage ends

4. If enrolling in Family Coverage, please included copies of the following:

• • • Birth Certificates for all dependents

    • Marriage Certificate and Spouse's Birth Certificate, if covering spouse

    • Page 1 from your latest tax filing (1040 or IT-201) if you have been married over 1 year. This is also used to confirm the SS numbers; you can white out the income.

5. Attach required documentation from carrier or employer WHEN current coverage is ending as well as change in employment that affected eligibility

6. Sign and date Form and submit paperwork to HHH Benefits Department at Central Office within 30 days of loss of coverage