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Human Resources Administration Building
University of California, Davis
One Shields Avenue
Davis, CA 95616

(530) 752-0530 phone

 
Human Resources > Benefits > DBA Resources > Forms & Materials
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Forms & Materials

It is suggested that a department maintain a supply of the materials identified on the Materials Chart below for its employees. These materials are available from:

MATERIALS CHART
All items available from the Fulfillment House.
ITEM # ITEM NAME REV. DATE PREVIOUS VERSIONS STILL VALID COMMENTS
3001 Military Leave Checklist 03/04 No
  • Should be given to all employees going on military leave
  • Refer employee to appropriate Benefits Office
3002 Indefinite Layoff Checklist 05/04 No
  • Should be given to employee with Layoff Notice
  • Refer employee to appropriate Benefits Office
3003 Leave Without Pay Checklist 07/05 No
  • Should be given to all employees going on an approved leave of absence
  • Refer employee to appropriate Benefits Office
3005 Disability Checklist 04/04 No
  • Should be given to all employees going on leave for medical reasons
  • Refer employee to appropriate Benefits Office regarding filing a disability claim
3006 Temporary Layoff Checklist 07/05 No
  • Should be given to employee with Layoff Notice
  • Refer employee to appropriate Benefits Office
3007 Termination of Employment Checklist 07/05 No
  • Should be given to all terminating employees
  • Refer employee to appropriate Benefits Office
3008 Furlough Checklist 07/05 No
  • Should be given to employee with Furlough Notice
  • Refer employee to appropriate Benefits Office
3009 Family Changes Checklist 07/05 No
  • Should be given to employee with a change in family status
3010 Family & Medical Leave Checklist 11/04 No
  • Should be given to employee whose leave is qualified under FMLA
  • Refer employee to appropriate Benefits Office
3013 Paid Leave Checklist 05/03 No
  • Should be given to an employee who is going on a paid leave
  • Refer employee to appropriate Benefits Office
3014 Sabbatical Leave Checklist 07/05 No
  • Should be given to an employee who is going on sabbatical leave
  • Refer employee to appropriate Benefits Office
3104 Pregnancy & Newborn Child Factsheet 12/03 No
  • Should be given to an employee who is expecting a newborn child
  • Refer employee to appropriate Benefits Office
UBEN 1039 Returning to UC Employment after Retirement 05/05 No
  • Send completed form to approriate Benefits Office
  • Refer employee to appropriate Benefits Office for counseling
UBEN 109 Notice to UC of a COBRA Qualifying Event 01/05 No
  • Attach to UPAY 850 form to deenroll family member and send completed forms to appropriate Benefits Office
UCRS 419 Statement Concerning Your Employment in a University Position Not Covered by Social Security 01/05 No
  • Mail directly to UCOP
  • Required of all newly-hired employees who are not covered by Social Security
UPAY 717 DepCare/HCRA Enrollment Salary Reduction Agreement 08/05 No
  • Send to appropriate Benefits Office
UPAY 850 On-line Enrollment, Change, Cancellation or Opt Out 02/05W No
  • Employees enrolling adult dependents who do not have a Social Security Number must use the UPAY 850
  • Employees making non-Open Enrollment and Life Event (birth, death, marriage) changes should use the UPAY 850
  • Send to Employee Benefits
  • New hires, rehires (following a break in service of 120 days or more) and continuing employees newly eligible for benefits must enroll electronically
  • Open Enrollment changes must be made using the OE web application
UPAY 919 DepCare/HCRA Enrollment, Change, or Cancellation 05/05 No
  • Send to appropriate Benefits Office

For other forms or publications available for download, please see the following: