Benefits Forms and Documents | Human Resources

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Benefits Forms and Documents

Please click on each of the following tabs to locate the forms and documents associated with the Benefits topic.

Health & Welfare
Retirement & Savings
Disability
Sample Letters

Health & Welfare
A Complete Guide to Your UC Health Benefits	AD&D Insurance Brochure	Affordable Care Act Exchange Notice		UCnet Forms & Publications
Delta Dental PPO Evidence of Coverage	DeltaCare USA Evidence of Coverage	DepCare Summary Plan Description		Enrollment, Change, Cancellation, Or Opt Out—Employees Only, UPAY850
Health FSA Summary Plan Description	Medical Plan Chooser	Medical Plan Summary		Notice To UC Of A COBRA Qualifying Event, UBEN109
Supplemental Life/Dependent Life Insurance Short-Form Health Questionnaire	Termination of Employment Checklist	Vision Plan Summary of Benefits		For information about temporary layoffs, go to the roadmap - What to do if you're laid off temporarily

Retirement & Savings
A Complete Guide to Your UC Retirement Benefits	Defined Contribution Summary Plan Description	Lump Sum Cashout Factsheet		Qualified Domestic Relations (QDROS) Factsheet
Retirement Handbook	Retirement Initiation Kit Request Form	Returning to UC Employment After Retirement Factsheet		Special Tax Notice for Plan Distributions
Your Guide to Survivor and Beneficiary Benefits	Tax-Deferred 403(b) Summary Plan Description	Tax-Deferred 457(b) Summary Plan Description		UCRP Service Credit Purchase Guide
UCRP 1976 Tier Summary Plan for Members with Social Security

Disability
Attending Physician’s Statement	Authorization to Release Medical Records	Authorization to Release Medical Records (Mental Health)		DepCare Flexible Spending Account
Disability Benefits Form (DBF)	Disability Information for Faculty	Family Changes Checklist		Family and Medical Leave Benefits Checklist
FML Return to Work Certification	Health FSA	Leave of Absence Request Form		Medical Benefits Summary Booklet
Pregnancy, Newborn and Adopted Child Factsheet	Reimbursement Agreement	Reporting Your Disability Claim		UCRP Disability Income
Stay-at-Work/Return-to-Work (SAW/RTW) Program	Supplemental Disability Insurance Plan Booklet	UCR Parking Services - Payroll Deduction/Cancellation Request form

Sample Letters
Sample letters to employees who appointments have changed and will no longer have benefits:	Core	Full or Mid-level		Full
Letters to employees whose appointments have changed and their benefits will be affected.	No Benefits or Core Benefits to Full Benefits No Benefits to Core Benefits	No Benefits or Core Benefits to Mid-level Benefits Postdoc Benefits to Mid-Level Benefits		No Benefits or Core Benefits to Full Benefits for Lecturers