How do I add a new family member to my insurance?

To enroll a newly-eligible family member, you must submit form UPAY 850 to the Benefits Office within your period of initial eligibility (PIE). Your PIE is 31 calendar days and begins on the date of the qualifying event. It ends on the last business day of that 31-day period. For additional information, please see the Group Insurance Eligibility Factsheet.

When completing the form, adhere to the following guidelines:

• Complete Section 1.
• Under Section 2, check appropriate box and complete the Comments section if requested.
• Under Section 4, qualifying additions to the family allow an employee to enroll into or increase coverage for Supplemental Life.
• Under Section 4, qualifying additions to the family allow an employee to enroll the new family member into Dependent Life.
• Under Section 5, list only the family member to be added. Other family members already enrolled need not be listed.
  • Circle "E" for Enroll.
  • Enter date of event. For example; birth, adoption or marriage/partnership date.
  • Enter family member's name, sex, relationship and birth date.
  • SSN is only required for spouse or domestic partner.
  • Indicate plans to which family member is to be added.
  • Enter primary care physician information as appropriate*.
  • Sign and date form.

*If you are adding your new family member to your medical plan and you are enrolled in Blue Cross PLUS, Health Net or Western Health Advantage, you will need to designate a Primary Care Physician for that dependent. You may search for doctors (and their corresponding identification numbers) using the internet; see your medical plan's website.