Form

Description

Campus

Health Benefits Enrollment Form for Life Event Use this form to enroll in, change, cancel, or opt out of insurance plans for yourself and/or your eligible family members during a Life Event (Marriage, Divorce, Loss of Coverage, Move out of Service area, etc.). Please submit form to the UC Path Center.  UC Davis /
UC Davis Health
Health Benefits Enrollment Form for Newly Eligible Employees Use this form to enroll in insurance plans if you are newly eligible to receive employee benefits (New employees, employees who became eligible for benefits after a change in job or appointment). Please submit form to the UC Path Center. UC Davis /
UC Davis Health
Late Enrollment Request Form This form is for employees who need to enroll in benefit plans once they have missed the open enrollment period (OEP) or period of initial eligibility (PIE), or for Faculty Second PIE. Please submit form to the UC Path Center. UC Davis /
UC Davis Health
HSA, Life Insurance, Voluntary Disability, and AD&D Change Form This form is used to enroll, cancel, or change coverage on a Health Savings Account (HSA), Life Insurance, Voluntary Disability, or AD&D insurance. Please submit form to the UC Path Center. UC Davis /
UC Davis Health
Postdoctoral Health Benefits Enrollment Form for Newly Eligible Employees Use this form to enroll in insurance plans if you are newly eligible to receive Postdoc benefits (New Postdoc or a Postdoc who became eligible for benefits after a change in job or appointment). Please submit form to the UC Path Center. UC Davis /
UC Davis Health
Dependent Information Update Form Use this form to update your dependent's information (name misspelled, Social Security number incorrect, etc) in UC Path. Please submit form to the UC Path Center. UC Davis /
UC Davis Health
Notice to UC of a COBRA Qualifying Event 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. Please submit form to the UC Path Center.

UC Davis /
UC Davis Health

UBEN 116 Designation of Beneficiary-Employees Current employees may use the UC Retirement 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 address on form) UC Davis /
UC Davis Health
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 address on form)
UC Davis /
UC Davis Health
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.) UC Davis /
UC Davis Health
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.) UC Davis /
UC Davis Health