Forms & Publications

By Title

A

• Academic Appointee Summer Salary Benefit Fact Sheet
• Academic Student Employee and Graduate Student Researcher Childcare Reimbursement (UBEN 254)
• Accelerated Benefit Option Form
• Accident Certificate of Insurance
• AD&D Plan Booklet for Employees
• AD&D Plan Booklet for Retirees
• Address Change Notice (UBEN 131)
• Adoption Assistance Plan Claim Form
• Adoption Assistance Plan Policy
• Adoption Assistance Plan Verification Form
• Affidavit of Overage Disabled Child Eligibility
• Affidavit of Unregistered Domestic Partner Eligibility
• Amendment to AD&D agreement
• Application for Disability Income (UCRS 156)
• Application for No Lapse in Pay option (UCRS 168)
• ARAG Plan Booklet
• ASE and GSR Child Care Reimbursement Program Fact Sheet

B

• Basic Disability Benefits Summary
• Basic Disability Benefits Summary (Spanish)
• Basic Disability Certificate of Coverage
• Being laid off
• Benefits for Domestic Partners
• Benefits of Belonging
• Breastfeeding resources

C

• Changes to Your Retiree Medical Benefits
• Childrens Health Insurance Program Model Notice
• COBRA Rates & Tip Sheet
• COBRA Rates & Tip Sheet (2020)
• Complete Guide to UC Health and Welfare Benefits
• Complete Retirement Benefits Guide for Employees
• CONEXIS Guide to Expenses
• CORE Benefits Summary
• CORE Plan Booklet
• CORE Plan Booklet (2023)
• CORE Prescription Drug Plan Summary Plan Description
• CORE Prescription Drug Plan Summary Plan Description (2023)
• CORE Prescription Drug Summary Plan Description
• Critical Illness Certificate of Insurance

D

• DC Plan Regulations
• Declaration of Domestic Partnership (UBEN 250)
• Declaration of Tax Dependency (UPAY 886)
• Defined Contribution Plan Summary Plan Description
• Definiciones y Documentos Requeridos - Family Member Verification
• Definitions and Required Documents
• DeltaCare Plan Booklet
• DeltaCare Plan Booklet (2023)
• DeltaCare Plan Summary
• DeltaCare Plan Summary (2023)
• Delta Dental Plan Highlights
• Delta Dental PPO Plan Booklet
• Delta Dental PPO Plan Booklet (2023)
• Delta Dental PPO Plan Highlights (2023)
• Demographic Data Transmittal SP
• DepCare FSA Claim Form (WageWorks)
• DepCare FSA Enrollment, Change, or Cancellation Salary Reduction Agreement - for Academic Student Employees (UPAY 919-ASE/GSR)
• DepCare FSA Summary Plan Description
• DepCare FSA Summary Plan Description for Postdoctoral Scholars
• Dependent Care FSA for Academic Student Employees
• Designation of Alternate Beneficiary (UBEN 119)
• Designation of Beneficiary - Employees (UBEN 116)
• Designation of Beneficiary - Retirees, Former Employees & Others (UBEN 117)
• Direct Deposit for Monthly Benefits (UCRS 160)
• Direct Deposit for Retiree Monthly Benefits Fact Sheet
• Disability Benefits for Faculty Fact Sheet
• Disability Policy
• Disability Return-to-Work Fact Sheet - member after April 1, 1980
• Disability Return-to-Work Fact Sheet - member before April 1, 1980
• Disability Return-to-Work Fact-Sheet - safety members
• Distribution Request - CAP Balance (UBEN 142 CAP)
• Distribution Request — Refund of Accumulations (UBEN 142)
• Document Submission Steps
• Domestic Relations Orders (DRO) Fact Sheet
• Domestic Relations Orders (DROs)

E

• Election to Change Primary Retirement Benefit from Savings Choice to Pension Choice (UCRS 216)
• Eligibility Appeal Form for Health & Welfare Benefits Plans (UBEN 177)
• Enrollment Form for UC Medicare Choice (UBEN 121)
• ERIT Contract
• ERIT Contract Amendment

F

• Family & Medical Leave Fact Sheet
• Family Changes Fact Sheet
• Family Member Eligibility Verification FAQ
• From Disability to Retirement Fact Sheet
• FSA Claim Form (WEX)

G

• Group Insurance Eligibility Fact Sheet for Retirees

H

• Health Care Facilitator Program
• Health Care FSA Summary Plan Description for Postdoctoral Scholars
• Health FSA Claim Form (WageWorks)
• Health FSA Summary Plan Description
• Health Net Seniority Plus out of area list
• Hospital Indemnity Certificate of Insurance

I

• Infertility Benefits Fact Sheet
• Instructions for Online Submission of Evidence of Insurability
• Instructions for Online Submission of Evidence of Insurability
• Instructions for Online Submission of Evidence of Insurability (Spanish)
• International ACH Transaction Form

K

• Kaiser HMO Summary of Benefits and Coverage
• Kaiser Permanente Booklet
• Kaiser Permanente HMO Booklet (2023)
• Kaiser Permanente Senior Advantage Creditable Coverage Notice
• Kaiser Permanente Senior Advantage out-of-area list
• Kaiser Senior Advantage Booklet
• Kaiser Senior Advantage Booklet (2023)
• Kaiser Senior Advantage Summary

L

• Leave Without Pay Fact Sheet
• Legal Insurance from ARAG Highlights
• Legal Insurance from ARAG plan summary
• Legal Insurance from ARAG plan summary (Spanish)
• Life Insurance Guaranty Association Notices
• Life Insurance Plan Booklet
• Lincoln Basic Disability Benefits Summary (2023)
• Lincoln Long-Term Disability Benefits Summary (2023)
• Lincoln Short-Term Disability Benefits Summary (2023)
• Long-Term Disability Benefits Summary
• Long-Term Disability Benefits Summary (Spanish)
• Lump Sum Cashout Fact Sheet

M

• Medical Coverage Opt Out During Pandemic (UBEN 230)
• Medicare Advantage Plan Disenrollment Form (UBEN 101)
• Medicare Advantage Universal Enrollment/Election Form for Kaiser Senior Advantage (UBEN 127)
• Medicare Fact Sheet
• Minimum Required Distributions Fact Sheet

N

• Navitus (PDP) Enrollment Form for UC Medicare PPO or UC High Option Supplement to Medicare (UBEN 123)
• Navitus MedicareRx (PDP) Evidence of Coverage
• Notice to UC of a COBRA Qualifying Event (UBEN 109)

O

• Optum Behavioral Health Booklet (2023)
• Optum Behavioral Health Plan Booklet
• Optum Behavioral Health Summary of Benefits and Coverage
• Optum Behavioral Health Summary of Benefits and Coverage (2023)
• Overview of UC Benefits for Tenure-Track Faculty

P

• Paid leave
• Partial Disability: Stay At Work/Return to Work Fact Sheet
• Pension Choice Covered Compensation Limit for Reciprocal CalPERS Classic Members (UBEN 300)
• Personal Accident Insurance Plan
• Plan Booklet Archive
• Postdoctoral Scholars Benefits Plan Transgender Health Benefits Fact Sheet
• Postdoctoral Scholars Child Care Reimbursement Factsheet
• Pregnancy, Newborn Child and Adopted Child Fact Sheet
• Pretax Transportation Program Fact Sheet and Form

Q

• Quit Power

R

• Request Form for Retroactive Use of 2021 EPSL
• Request for Retirement Initiation Packet
• Retiree AD&D Enrollment Form
• Retiree Continuation, Enrollment, or Change - Medical, Dental, &/or Legal Plan (UBEN 100)
• Retirement Benefits Decision Guide
• Retirement Benefits Decision Guide for rehired, newly eligible and former CalPERS-covered employees
• Retirement Benefits Fact Sheet
• Retirement Handbook
• Retirement Savings Program Information for Safe Harbor Participants
• Returning to UC Employment After Retirement Fact Sheet

S

• Savings Choice participants: Your opportunity to switch to Pension Choice
• ScholarShare Payroll Deduction Form
• Seguro legal de ARAG (2023)
• Seguro legal de ARAG puntos principales
• Service Credit Purchase Information Request (UCRS 169)
• Service Credit Verification Request (UBEN 132)
• Short-Term Disability Benefits Summary
• Short-Term Disability Benefits Summary (Spanish)
• Special Tax Notice for UC Retirement Plan Distributions
• Statement Concerning Your Employment in a University Position Not Covered by Social Security (UCRS 419)
• State Oath of Allegiance, UC Patent Policy and Patent Acknowledgment (UPAY 585)
• Su Guía de Beneficios por Discapacidad en la UC
• Summary of Benefits and Coverage
• Summary of Benefits and Disclosure Form
• Supplemental Health Plans Guide
• Supplemental Health Plans Guide
• Supplemental Health Plans Guide (2021)

T

• Tax Withholding Election (Nonresident Aliens) (UBEN 106 NR)
• Tax Withholding Election for UCRP Income (UBEN 106)
• Temporary Layoff
• Termination of Domestic Partnership (UBEN 253)
• Termination of Employment Benefits Fact Sheet
• The Roth option in the UC Retirement Savings Program
• Tobacco Cessation Resources
• Transgender Health Benefits Fact Sheet
• TRICARE for Life
• Trustee-to-Trustee Transfer Request for UCRP Service Credit (UCRS 186)

U

• U560/644 Multi-Location Appointment/Interlocation One-Time Payment Form
• UBEN 255
• UC Blue & Gold Summary of Benefits and Coverage
• UC Blue & Gold Summary of Benefits and Coverage (2023)
• UC Care Benefits Summary (2022)
• UC Care Prescription Benefit Booklet (2017)
• UC Care Prescription Drug Plan Summary Plan Description
• UC Care Prescription Drug Plan Summary Plan Description (2023)
• UC Care Summary of Benefits and Coverage (2021)
• UC Healthcare Plan Notice of Privacy Practices - Self-Funded Plans
• UC Health Savings Plan Benefits Summary (2022)
• UC Health Savings Plan Booklet
• UC Health Savings Plan Booklet (2019)
• UC Health Savings Plan Booklet (2023)
• UC Health Savings Plan Prescription Drug Plan Summary Plan Description
• UC Health Savings Plan Prescription Drug Plan Summary Plan Description (2023)
• UC Health Savings Plan Summary of Benefits and Coverage
• UC High Option Coverage Summary
• UC High Option PDP Coverage Summary (2023)
• UC High Option Plan Booklet
• UC High Option Plan Booklet (2023)
• UC High Option Prescription Drug Plan Evidence of Coverage
• UC High Option Supplement to Medicare Creditable Coverage Notice
• UC HSP Quiz
• UC Medicare Choice Benefits Summary
• UC Medicare Choice Complete Drug List (2023)
• UC Medicare Choice Plan Booklet
• UC Medicare Choice Plan Guide
• UC Medicare PPO Coverage Summary
• UC Medicare PPO PDP Coverage Summary (2023)
• UC Medicare PPO Plan Booklet
• UC Medicare PPO Plan Booklet (2023)
• UC Medicare PPO Plan Creditable Coverage Notice
• UC Medicare PPO Plan Without Prescription Drugs Plan Non-creditable Coverage Notice
• UC Medicare PPO Prescription Drug Plan Evidence of Coverage
• UC Medicare PPO Summary of Benefits (2020)
• UC Medicare PPO without Prescription Drugs Booklet
• UC Medicare PPO without Prescription Drugs Booklet (2023)
• UC Medicare PPO without Prescription Drugs Summary of Benefits
• UC Medicare PPO without Prescription Drugs Summary of Benefits
• UC Retirement Choice Program—Pasos para Elegir Opciones de Pension u Opciones de Ahorro
• UC Retirement Choice Program—Steps for Electing Pension Choice or Savings Choice
• UCRP/CalPERS Reciprocity Fact Sheet
• UCRP/CalSTRS Concurrent Retirement Fact Sheet
• UCRP 1976 Summary Plan Description (for Members Without Social Security)
• UCRP 1976 Tier Summary Plan Description
• UCRP Safety Members Summary Plan Description
• UCRP Service Credit Purchase Guide
• UCRP Special Durable Power of Attorney fact sheet
• UCRP Summary Plan Description (for Tier Two Members)
• UCRP Summary Plan Description for 2013 Tier Members

V

• Via Benefits Frequently Asked Questions
• Voluntary Long-Term Disability Certificate of Coverage
• Voluntary Self-Identification of Race, Ethnicity and Veteran Status (U5605)
• Voluntary Short-Term Disability Certificate of Coverage
• VSP Plan Booklet
• VSP Plan Booklet (2023)
• VSP Plan Summary for Employees
• VSP Plan Summary for Employees (2023)
• VSP Plan Summary for Retirees
• VSP Plan Summary for Retirees (2023)

W

• Welcome Kit
• WHA copay summary
• WHA creditable Coverage Notice
• Which Medical Plan is Right for You?
• Which medical plan is right for you? (8.5 x 11)
• Which Medicare Plan is Right for You?
• Which Medicare Plan Is Right for You? (8.5 x 11)

Y

• Your benefits at a glance
• Your Guide to Survivor & Beneficiary Benefits for Family Members & Beneficiaries of Active UC Employees
• Your Guide to Survivor & Beneficiary Benefits for Family Members & Beneficiaries of Former UC Employees
• Your Guide to Survivor & Beneficiary Benefits for Family Members & Beneficiaries of UC Retirees & Disabled Members Receiving UCRP Income
• Your Guide To UC Disability Benefits