Loss of Dependent's Coverage

What to do for certain qualifying events in NYSHIP - for HIP changes, use THIS FORM

NOTE - voluntary cancellation of coverage is NOT a qualifying event unless your dependent is cancelling during his/her employer's open enrollment

Dependent losing health coverage

1. Complete the NYSHIP Transaction Form  to [A]dd your dependent  and Change to Family coverage, if necessary

2. When enrolling a dependent, please included copies of the following:

• • • Birth Certificate

    • 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.

3. Attach required documentation from carrier or employer WHEN current coverage is ending; must include name of individual losing coverage

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