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New York State
Participating Agency (PA) & Participating Employer (PE) Employee Information Day/Health Fair Request Form

Congratulations on hosting an Employee Information Day or Health Fair. This request form has been designed by the Employee Benefits Division (EBD) and is for New York State Participating Agencies (PA) and/or Participating Employers (PE) groups, only. Please complete this form in its entirety and submit your request, at least 4 weeks prior to your event date. After your initial email confirmation, an EBD Communications Unit representative will contact you to confirm receipt of your request.

An Empire Plan representative must be approved to attend before Health Maintenance Organizations (HMOs) are authorized to attend. Please await EBDs confirmation, we will provide you the name of the representative(s) scheduled to attend your event, usually, within 3 to 5 business days.

* Fields marked with an asterisk are mandatory.

Your information

Contact Person for the Health Fair (if different than above)

Your Agency Health Benefits Administrator (HBA) must attend the health fair event; if your HBA is unavailable, a Human Resources or Personnel Unit staff member may attend in their place. Please provide the name/title as confirmation of attendance.

The following information is used to determine an appropriate volume of benefit specific publications and materials for your event, exact data is not required. Please be conservative in your estimations as publications and shipping are provided at no cost to your agency and NYSHIP participation is not contingent upon estimated attendance. The New York State Department of Civil Service strives to provide representatives and materials for every event. Thank you for your cooperation.

At the conclusion of your event all leftover materials may be retained for future use by your Human Resources or Personnel Office; however, our representatives will not take excess materials and we do not provide return shipping labels to return these publications to our inventory.

Please call the EBD Communications Unit (ph) 518-457-7577; (fax) 518-402-4697, if you require assistance completing the form, or have any questions. Good luck with your event!

Name and street address where materials can be sent in advance (if different from above)

Facility Instructions

Provide any information and details to assist EBD in preparation for your event, i.e., generic driving directions, campus or facility maps, visitor parking, security check-in or vendor check-in instructions, etc



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