Number

Name

Description

I-9

Employment Eligibility Verification Form

The requested information meets UC's legal obligations as an employer.

U5605

Demographic Data Transmittal

The requested information meets UC's legal obligations as a Federal contractor.

UCRS 419

Statement — Employment not Covered by Social Security

Signature meets UC's obligation under Social Security Act Section 419(c) of Public Law 108-203.

University Benefits

Number

Name

Description

UBEN 100

Retiree Continuation, Enrollment, or Change— Medical, Dental and/or Legal Plan

Use this form to continue UC-sponsored coverage from employment into retirement, continue coverage when applying for UCRP disability income, cancel or change plans after retirement, enroll if you are a survivor, or add or delete eligible family members.

UBEN 101

Medicare Advantage Prescription Drug Plan Disenrollment Form

If you are not enrolling in another Medicare Advantage Prescription Drug plan, complete this form to disenroll yourself and/or your enrolled family members from your current Medicare Advantage Prescription Drug plan.

UBEN 106

Tax Withholding Election for UCRP Income

Use this form to elect or change your withholding for UCRP monthly retirement income, survivor income, or disability income.

UBEN 106NR

Tax Withholding Election (Nonresident Aliens)

Use this form if you are a former UC employee and a nonresident alien receiving payment(s) outside of the U.S.

UBEN 108

COBRA Continuation Open Enrollment and Change Form

Use this form to change or cancel plans, or to add or delete a dependent.

UBEN 109

Notice to UC of a COBRA Qualifying Event

Use this form to notify UC of a divorce/legal separation/annulment, termination of domestic partnership, or a dependent's loss of eligibility, and to request a COBRA application packet.

UBEN 110

HMO Medical Plan Transfer for Annuitants

Use this form to transfer from your current UC California HMO to another UC California HMO medical plan ONLY.

UBEN 116

Designation of Beneficiary—Employees

Use this form to designate a beneficiary to receive death benefits from UCRP (including CAP payment, if any) and for Life Insurance and AD&D.

UBEN 117

Designation of Beneficiary—Retirees, Former Employees and Others

Use this form to designate a beneficiary to receive death benefits from UCRP (including CAP payment, if any).

UBEN 119

Designation of Alternate Beneficiary—Expanded Dependent Life and AD&D

Use this form to name or change beneficiaries.

UBEN 126

Medicare Declaration

Complete this form when you, your spouse, domestic partner, or other eligible family member who is covered by a UC medical plan becomes eligible for Medicare Part A.

UBEN 131

UC Benefits Address Change For Retirees and Former Employees

Submit this form if your address has changed and you an inactive UCRP member or a retiree. (Active employees should use "At Your Service Online" (online application) or report changes to local Accounting Office.)

UBEN 132

Service Credit Verification Request—UCRP

Use this form to request service credit adjustments that do not require payment; to correct incomplete or incorrect data that could affect your benefits (service credit, UCRP entry date, or your birthdate); or to complete your buyback in one lump-sum, after-tax payment.

UBEN 143 - CSU

Defined Contribution Plan Distribution Kit for CSU Safe Harbor Participants

Use this kit if you have left CSU employment and want to take a distribution from the Defined Contribution Plan. Includes a Special Tax Notice and a Distribution Request form (UBEN 143-CSU).

UBEN 250

Declaration of Domestic Partnership

If you have not registered your domestic partnership with the State of California, this declaration is required to determine your partner’s eligibility for UCRP survivor and death benefits.

UBEN 253

Termination of Domestic Partnership

Use this form to notify UC HR/Benefits that your domestic partnership has ended.

University of California Retirement System

Number

Name

Description

UCRS 160

Enrollment, Change or Cancellation—Direct Deposit

Retirees should use this form to begin, change or cancel the direct deposit of their monthly UCRP benefit.

University Payroll

Number

Name

Description

UPAY 585

State Oath of Allegiance, Patent Policy, and Patent Acknowledgement

The requested information meets UC's legal obligations as an employer.

UPAY 717

DepCare/HCRA Enrollment Salary Reduction Agreement — During a Period of Initial Eligibility or Open Enrollment

Complete this form to enroll in DepCare or HCRA when you are newly eligible or during Open Enrollment. Use form UPAY 919 for all other actions.

UPAY 850

Enrollment, Change, Cancellation, or Opt Out—Employees Only, Health and Welfare Plans

Use this form to enroll in, change, cancel, or opt out of insurance plans for yourself and/or your eligible family members.

UPAY 884

Pretax Transportation Program Factsheet

This factsheet includes general information about UC's Pretax Transportation Program. Includes form UPAY 884 (UC Pretax Transportation Deductions or Cacellation or Re-enrollment.

UPAY 919

DepCare/HCRA Enrollment, Change or Cancellation — Salary Reduction Agreement

Use this form to: Enroll due to an eligible mid-year status event, re-enroll in either plan during this calendar year, cancel your coverage, change your contribution, or transfer between UC locations.

Note: To enroll in HCRA or DepCare because you are newly hired or rehired, or because you are hired into an appointment making you eligible for the plan, use form UPAY 717.