Category:Benefits
Title:NYS Health Insurance Transaction Form (TA/GA Health Insurance Enrollment Form)
Type:For State/Student Employees
 
Format:Adobe Acrobat (PDF)1Microsoft Word/Excel
Form:PS-404G.pdfPS-404G.doc
Size:398 KBytes89 KBytes
Form Date:06/0506/05

Related Link: http://www.stonybrook.edu/hr/benefits/state/student.shtml

Special Notes:


This is the Graduate Student Health Insurance Enrollment Form for TA's and GA's.


Instructions and Examples:


To process your health insurance enrollment application, you must attach a copy of the following items for yourself and each person you wish to cover. Your enrollment application will not be processed if the following items are not attached. You MUST make your own copies and attach it to your enrollment application. You may bring or mail your enrollment application and proofs to the address listed below. This is a Civil Service Requirement. Please read both sides of the health insurance enrollment application, your signature is required.

For Individual coverage a student must submit the following items:
  • Birth Certificate (US citizen)
  • Passport for International Students if they don’t have a birth certificate
  • Social Security Card (enrollment application can not be processed without a Social Security Number)

If student is enrolling spouse or child they will need to submit the following items:
  • Birth Certificate (US citizen)
  • Passport for International adults only (children must have a birth certificate)
  • Social Security Card
  • Marriage Certificate-For International Students, Marriage Certificate must be translated to English
  • Proof of full-time student status (for your dependents 19-25 years old)
  • Proof of Support/Dependence for other children (if applicable)
  • Proof of Disability (if applicable)


* If you are an International Student all proofs MUST be translated to English.

* COPIES WILL NOT BE MADE IN THE INSURANCE OFFICE

Lisa Coleman
Student Health Center
Stony Brook, NY 11794-3191


Revision History:
06/05

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