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Benefits Forms

Benefits

UPAY 850
For Benefits Enrollment and Changes.

Request for Reduced Fee Enrollment
For Employees who are also Students at UC Merced.

Liberty Mutual Statement of Health
Use when enrolling or increasing Supplemental Disability.

Formulario De Prueba De Asegurabilidad
Liberty Mutual Statement of Health in Spanish.

Prudential Statement of Health
Use when enrolling in or increasing Life Insurance amounts.

Reciprocity Form and Information
Apply for reciprocity with CalPERS using this form.

Verification of Previous Employment
For incoming employees, to transfer Vacation/Sick from other State Agencies.
For all separating employees, must be completed by the department and sent to the Benefits Office.

Leaves of Absence

Leave of Absence Request

Return to Work Certification

Medical Certification for Employee
Medical Certification for Family Member
Medical Certification for Employee’s Pregnancy Disability

Declaration of Relationship for FMLA

Catastrophic Leave Program

Catastrophic Leave Donation Form
Catastrophic Leave Program Policy and Procedures (Includes Application Form)
Catastrophic Leave Medical Certification

Workers Compensation