Forms

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Forms

Title Short Description Topic Campus
UBEN 109 Notice to UC of a COBRA Qualifying Event

Use this form to notify the UC of the occurrence of a qualifying event that results in the involuntary loss of eligibility for coverage under the UC group insurance plans.

Benefits UC Davis and UC Davis Health Download
UBEN 116 Designation of Beneficiary-Employees

To update your beneficiaries for UCRP and insurance plans, log into UC Retirement At Your Service (UCRAYS). For your UC retirement Savings Plans accounts, log into Fidelity NetBenefits. Employees may also complete and submit this form to the address on the form.

Benefits UC Davis and UC Davis Health Download
UBEN 119 Expanded Dependent Life and AD&D Insurance Designation of Alternate Beneficiary

You are automatically the beneficiary if a family member who is covered under your Expanded Dependent Life and/or Accidental Death and Dismemberment (AD&D) insurance plans dies. However, if you want someone else to receive benefits if a covered family member dies, complete this form. (Submit form to UC/HR Benefits address on form.)

Benefits UC Davis and UC Davis Health Download
UBEN 132 UC Retirement Plan Service Credit Verification Request

Use this form for service credit adjustments that do not require payment or to correct incomplete or incorrect data that could affect your UCRP benefits (UCRP service credit, UCRP entry date, or your birthdate). (Submit form and records to UCOP address on form.)

Benefits UC Davis and UC Davis Health Download
UCRS 419 Statement Concerning Your Employment in a University Position Not Covered by Social Security

This form explains how not being subject to Social Security may affect future Social Security benefits to which the individual may become entitled. This form complies with the Social Security Protection Act. (Submit form to UC HR/Benefits address on form.)

Benefits UC Davis and UC Davis Health Download