Benefits Forms
Use this form to notify the UC of the occurrence of a qualifying event that results in the involuntary loss of eligibility for coverage under the UC group insurance plans.
UBEN 116 Designation of Beneficiary-Employees
Current employees may use the At Your Service website to name or change beneficiary(ies) for death benefits from the UC-sponsored retirement/savings and insurance plans in which you are enrolled (other than 403(b) Fidelity and Calvert mutual fund accounts). If unable to use the web, the employee may complete this form.
(Submit form to UC/HR Benefits address on form.)
UBEN 119 Expanded Dependent Life and AD&D Insurance Designation of Alternate Beneficiary
You are automatically the beneficiary if a family member who is covered under your Expanded Dependent Life and/or Accidental Death and Dismemberment (AD&D) insurance plans dies. However, if you want someone else to receive benefits if a covered family member dies, complete this form.
(Submit form to UC/HR Benefits address on form.)
UBEN 132 UC Retirement Plan Service Credit Verification Request
Use this form for service credit adjustments that do not require payment or to correct incomplete or incorrect data that could affect your UCRP benefits (UCRP service credit, UCRP entry date, or your birthdate).
(Submit form and records to UCOP address on form.)
UCRS 419 Statement Concerning Your Employment in a University Position Not Covered by Social Security
This form explains how not being subject to Social Security may affect future Social Security benefits to which the individual may become entitled. This form complies with the Social Security Protection Act.
(Submit form to UC HR/Benefits address on form.)
UPAY 717 DepCare/HCRA Salary Reduction Agreement
Use this form to enroll in, change or cancel your contributions to the Dependent Care Assistance Program or to enroll in, change or cancel your contributions to the Health Care Reimbursement Account. Note: The effective date of coverage is different from other plans. Refer to the Summary Plan Description or your Benefits Office for additional information.
(Submit form to Employee Benefits.)
UPAY 850 Enrollment, Change, Cancellation or Opt-Out
Use this form to enroll in, change, cancel, or opt out of insurance plans for yourself and/or your eligible family members.
(Submit form to Employee Benefits.)
UPAY 898 HMO Medical Plan Transfer
Use this form to transfer from your current UC California HMO to another UC California HMO medical plan ONLY. Please read the Employee Checklist before submitting this form.
(Submit form to Employee Benefits.)
UPAY 919 DepCare/HCRA Enrollment, Change, or Cancellation - Salary Reduction Agreement
Use this form to enroll due to an eligible mid-year status event, re-enroll during the same calendar year, change your contributions, cancel your coverage, and transfer between UC locations. Note: The effective date of coverage is different from other plans. Refer to the Summary Plan Description or your Benefits Office for additional information.
(Submit form to Employee Benefits.)
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