Open Enrollment

Open enrollment for the Benefits Fund begins on November 1, 2022 and runs through December 31, 2022, with a coverage effective date of January 1, 2023. During open enrollment, eligible individuals have the opportunity to enroll in or opt out of Benefits Fund health coverage without a qualifying event (such as the birth of a child or a marriage).

Individuals eligible to make changes to their Fund coverage during this two-month period include: 

  • Full-time employees who previously opted out of Benefits Fund health coverage because they had other coverage;
  • Part-time employees who previously waived Benefits Fund health coverage for any reason; 
  • Spouses and eligible dependents who weren't added to the coverage when they first became eligible; and
  • Full-time employees who have other health coverage and would like to opt out of the Benefits Fund.  

If you are not making any changes, you do not need to submit an enrollment form at this time.

When enrolling a spouse or dependents, the Fund requires you to provide Social Security numbers for each individual you're enrolling and submit a copy of the following documents:

  • Marriage certificate (for spouse)
  • Birth certificate (for dependents)

download your enrollment form

Click the DOWNLOAD FORM button below to access the Fund's 2022 Open Enrollment form. Print and fill out the form completely, then choose one of the options below to submit your form to the Fund.

Download Form


Mobile Upload

This is the easiest way to provide your completed enrollment form to the Fund. Use the button below to access our secure upload site. Once there, enter your first and last name, e-mail address, and company name (your current employer). Then, using the "Browse files" link, take a photo with your camera and upload it in one simple step.

Submit via e-mail

Simply sign your paperwork, scan it, and e-mail it to using the link below.

Submit via fax or mail

Fax your signed paperwork to (518) 869-2317 or mail it to:

NYSNA Benefits Fund
PO Box 12430
Albany, NY 12212-2430