The Empire Plan is a unique health insurance plan designed especially for public employees in New York State. Empire Plan benefits include inpatient and outpatient hospital coverage, medical/surgical coverage, Centers of Excellence for transplants, infertility and cancer, home care services, equipment and supplies, mental health and substance abuse coverage and prescription drug coverage.
Publications & Forms
Employees of the State of New York (NY)
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NYSHIP Publication Order Forms
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APSU
Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
Empire Plan Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
HMO Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
Council 82
Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
Empire Plan Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
HMO Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
CSEA
Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
Empire Plan Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
HMO Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
Courts
Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
Empire Plan Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
HMO Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
DC-37
Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
Empire Plan Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
HMO Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
SEHP
Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
SEHP CUNY Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
SEHP SUNY Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
MC
Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
Empire Plan Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
HMO Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
NYSCOPBA
NYSCOPBA - Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
Empire Plan Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
HMO Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
PBA
Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
Empire Plan Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
HMO Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.r
PEF
Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
Empire Plan Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
HMO Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
PIA
Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
Empire Plan Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
HMO Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
UUP
Order Publications Online - Order specific publications for your office or mail directly to the enrollee's home.
Empire Plan Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
HMO Quick Order - A complete package of group-specific materials mailed directly to the enrollee's home.
NYSHIP Insurance Forms and Support Material
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Health, Dental and Vision Forms for New York State
PS 404 (6/2025) NYSHIP Health Insurance Transaction Form for NYS & PE Employees
PS 405 (6/2020 L) NYSHIP Sick Leave Credit Option Election Form
PS 406.2 (6/2020 L) NYSHIP Health Insurance Deferral Election Form
PS 409 (8/19) Opt Out Attestation Form
PS 410 (6/2020 L) NYSHIP Sick Leave Credit Preservation Form
PS 425 Domestic Partner Series
PS 425 (9/2024) Instructions and Application for Enrolling Domestic Partners
PS 425.3 (9/2024) Dependent Tax Affidavit for Domestic Partners
PS 431 (03/06) Health Insurance and Dental/Vision Insurance for Employees on Leave Without Pay
PS 451 (9/2020 L) NYSHIP Statement of Disability for Dependents
PS 452 (10/2020 L) Application for Waiver of Empire Plan Premium
PS 457 (3/2025) NYSHIP Statement of Dependence for "Other" Children
PS 850 (6/2020 L) Change of Address Form (for NY Active Enrollees and for NY and PE Retirees)
Income Protection Plan (IPP)
Short Term Disability (STD) - Disability Claim Form (Download and photocopy as needed)
Long Term Disability (LTD) Forms
(Download and photocopy as needed)
Long Term Disability Claim Form - Employee Statement
Long Term Disability Claim Form - Employer Statement
Disability Claim Employee���s Physical & Cognitive Job Description
PS 1103 M/C Income Protection Plan Enrollment (Order on-line)
If you would like a paper copy of this form, please call the Department of Civil Service, Employee Benefits Division at 1-800-833-4344.
Income Protection Plan Enrollment (For Special Enrollees) (Download and photocopy as needed)
IPP (MetLife) Authorization to Disclose Information About Me (03/11) (Download and photocopy as needed)
Management/Confidential (M/C) Life Insurance
PS-932 (4/2020 L) M/C Life Insurance Transition to Retirement Notice
PS-934 (7/2024) M/C Group Life Insurance Transaction Form
PS-934.1 (4/2020 L) M/C Group Life Insurance Beneficiary Designation Form
Statement of Review for Continuance of Life Insurance Protection During Total Disability (9-15)
Young Adult Option Forms
Current Publications
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Guidelines for NYSHIP Participation at NY Agency Health Fairs
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HIPAA Documents
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Format Options
HTML (Hyper Text Markup Language)
This is the most commonly used coding language for creating web pages. The
code tells the web browser how to display page content and links. Most forms
and publications are available in this format.
PDF (Portable Document Format)
This is a format that displays the same on any computer system and with
the identical layout as the original print-published document.
All current forms and publications (except The Empire Plan Insurance Certificates
and General Information Books) on this website are available in this format.
WORD (Microsoft Word Document)
This format requires that Microsoft Word or Open Office (by Sun Systems) be available on the local computer for proper document viewing.
Text Version/Printable Version
These provide pages without any design elements. This option is available
on each web and publication page in the upper right corner of the screen.
Adobe Acrobat Reader:
Several of the publications and forms in this section are in PDF format. To open these documents you will need Adobe Acrobat Reader. Click on the logo at the bottom of this page, or the “PDF Help” buttons located throughout this section of the site, to go to Adobe’s free download page.
Printing:
To print a publication, open the document and click your cursor arrow on the text. Then click on the print button at the top of the browser window. To print a form offered in a PDF format, select the print button on the Adobe Acrobat Reader tool bar directly above the PDF document. If you have trouble printing a page, try an alternate browser or use the "Text Version/Printable Version" button on the top right of every page. Click on the "Print" button at the top of the browser window.
to read PDFs on this site