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Benefits Forms

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Benefit Forms

Description

 

Benefit eForms: Newly Eligible - New Hire

Use this Benefit eForm to enroll in benefit plans if you are newly eligible for benefits or a new employee. Your module should make this possible in your "Enroll in Benefits" UC Path link, however, you can fill out this form if needed in place of the module.

Benefit eForms: Life Event - Late Enrollment 

Download Instructions

Use this Benefit eForm to enroll in benefit plans for a life event that is outside of the PIE.

Benefits eForms: Submit a New Form

Use this Benefits eForm to enroll, cancel, or change Health Saving Account (HSA), Voluntary Disability, Life Insurance, Supplemental Health Plans and AD&D 

 

Evidence of Insurability

The EOI is a health questionnaire that helps us determine whether you and other dependent applicants qualify for new insurance or an increase in coverage.

 

Dependent Information Update

Use this form to update your dependent's information (incorrect date of birth,mispelled name, etc.).

  • Submit form to the UCPath Center.

 

Health Benefits OPT Out

The purpose of this form is to:

  1. allow employees to decline/opt out of University health coverage including medical, dental,  and/or vision; or
  2. allow employees who enrolled in medical coverage online via UCPath to decline/opt out of the Tax Savings on Insurance Premiums (TIP) program.
 
 
Use this form to notify UC of the occurence of any of the qualifying events (divorce/legal separation/annulment, termination of domestic partnership,or dependent's loss of eligibility) and to request a COBRA application packet.

  • Notice to UC of a COBRA Qualifying Event Instructions