Insurance Continuation Form
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32016 UCSC INSURANCE CONTINUATION FORM (ICF)
FOR UNIT 18 BENEFITS BRIDGE
When you are eligible for UC health and welfare plans, but have periods of no pay you must take immediate action in order to
continue or cancel your University insurance. Unpaid periods can be due to Benefits Bridge for Lecturers and other periods of
UC Employment with no pay, such as summer or holiday breaks.
IMPORTANT NOTICE: Failure to complete and return form and payments on time will result in automatic loss of benefits coverage.
Please read the instructions that follow for important information regarding your insurance plan rates and details on how to complete this
form.
If you do not know your benefit plan enrollments or rates, you may view them on-line by logging into:
Contact UCSC Benefits at (831) 459-2013 with any questions. Before completing this form you
should have submitted and had approved a UPAY 573 Sabbatical Leave/Leave of Absence form through your divisional HR office. For
additional Insurance Continuation Forms, you will need to make copies, contact the Benefits Office or go on-line to: shr.ucsc.edu/forms/shr-
1060.pdf.
Deadline: Completed forms, with continue/cancel elections for all benefit plans, and payments are due to the UCSC Payroll
Office no later than the 10
th
day of each month you are eligible for Benefits Bridge.
For example, if your pay stops Mar. 1
st
,
payments for April coverage are due March 10
th
.
ATTENTION REPRESENTED EMPLOYEES: Employee medical premium rates may differ for employees in some bargaining units. Check your current earnings statement
on-line:
https://atyourserviceonline.ucop.edu/ayso/
for your contribution amount.
Employee Information and Continuation/Cancellation Elections:
Name: _______________________________________
ID#: _______________________________________
Home Address: ________________________________________________________________________________
E-mail Address: _________________________________
Home Phone: __________________________________
Non-paid quarter: _______________________________
Dept. _______________________________________
I have received written commitment for reemployment. My reemployment date is: ___________________________
Monthly
# Months
Total Premium
Payroll
Insurance Plan
Continue
-OR-
Cancel
Premium Owed
Covered
Enclosed
Use
Medical: _______________
( )
( )
$_____________
# ______
$_____________
____________
Dental: ________________
( )
( )
$_____________
# ______
$_____________
____________
Vision Service Plan
( )
( )
$_____________
# ______
$_____________
____________
ARAG Legal
( )
( )
$_____________
# ______
$_____________
____________
Supplemental Life
( )
( )
$_____________
# ______
$_____________
____________
Basic Dependent Life
( )
( )
$_____________
# ______
$_____________
____________
Expanded Dependent Life
( )
( )
$_____________
# ______
$_____________
____________
AD&D
( )
( )
$_____________
# ______
$_____________
____________
Health FSA and DepCare FSA
n/a
n/a
____________
Total Premium Enclosed:
$_____________
Enclosed is my check/money order in the amount of $_________ (monthly) or $_________ (lump sum) made payable to
“UC Regents” for the following earnings month(s) [Coverage is paid for a month in advance – Mark ALL that apply]:
( ) Jan.
( ) Feb.
( ) Mar.
( ) April
( ) May
( ) June
( ) July
( ) Aug
( ) Sept.
( ) Oct.
( ) Nov.
( ) Dec.
Winter Quarter
Spring Quarter
Summer Quarter
Fall Quarter
By signing below, I understand that if I am late with my premium payments, my benefits will be cancelled and I will not be able to re-enroll
until I return to pay status. If any plans are cancelled, I will contact Benefits immediately upon my return to pay status.
Employee Signature: ______________________________________
Date: ____________
Mail completed form and applicable payment to: UCSC Payroll Office at 1156 High Street in Santa Cruz, CA 95064
OR deliver to the Payroll Office at 2300 Delaware Avenue in Santa Cruz (Walk-in hours: Mon-Fri 9am to noon).
Make a copy for your records!
Benefits Bridge 2016 shr-1060 (r.12.2015)
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