• It is imperative that you complete this form in its entirety in order to maintain your health benefits coverage.
  1. All enrollees must complete Section 1,2 and 4.
  2. All enrollees with family coverage must also complete Section 3.
  3. If the enrollee or any of their eligible dependents are covered by another insurance plan including a group health plan, Medicare or TRICARE for Life, the enrollee must complete Section 4 in its entirety.
     
• Please print the form.
  
• Please sign and date Section 5 of the form.
  
• Insert Re-enrollment Form in the yellow envelope provided to you. (If you have misplaced the yellow envelope, please insert a white business envelope and please write in the lower left hand corner. "Attn: EBU - Re-enrollment").
  
• Mail form to address below as soon as possible, but in any event no later than, Friday, January 16, 2004. Active employees are encouraged to return this form through Inter-Office Mail.
  

County of Suffolk
Dept. of Civil Service - Employee Benefits
P.O. Box 6100
Hauppauge, NY 11788-0099

Inter-office address:
Dept. Of Civil Service - Employee Benefits
North County Complex - Bldg. #158
Hauppauge

• If you have any questions, please contact the Employee Benefits Unit, S.C. Department of Civil Service/Human Resources, either by telephone (631-853-4866) or via e-mail (ebu@suffolkcountyny.gov).

Re-enrollment Form