Loss of Current Coverage

NOTE - voluntary cancellation of coverage is NOT a qualifying event unless the policy holder is cancelling during his/her employer's open enrollment period

Loss of current coverage 

1. NYSHIP Transaction Form or HIP Transaction Form to enroll in Individual or Family Coverage

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. Complete Item 13 and attach required documentation from carrier or employer WHEN current coverage is ending and WHY; must include names of individuals losing coverage

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