NYSHIP Health Coverage Request — Under the Young Adult Option

Enrollment form for young adult coverage in NYSHIP health insurance.

Download the Form

Download the NYSHIP Health Coverage Request - Under the Young Adult Option Form
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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:         

1. Attach documentation to verify eligibility of young adult

2. Make check payable to
Employee Insurance Pending Account

New York State Department of Civil Service
Employee Benefits Division - YAO
Albany, New York 12239

Need Help Completing the Form?

State Benefits

Human Resources

Phone: 716-645-7777

Email: ub-hr-benefits@buffalo.edu

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: December 2012

Owner: New York State Department of Civil Service