Insurance Continuation Form Page 3
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1
2
3If you wish to CANCEL coverage: Mark "Cancel" and return the form.
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NOTICE: It is your responsibility to complete the Insurance Continuation Form electing to cancel or continue coverage
for each plan while on Benefits Bridge; failure to do so will result in cancellation.
PREMIUM PAYMENT-Continuing Coverage
You will owe a premium for each pay period you will not receive a paycheck. Premiums are payable by check or money
order by the 10
th
of the month you are on Benefits Bridge. You may pay the premiums for the entire leave in a lump
For example, if your pay stops Mar. 1st,
sum or on a monthly basis. Premiums for coverage are paid in advance.
payments for April coverage are due March 10th.
See the online calendar
(https://financial.ucsc.edu/SiteCollectionDocuments/Insurance_Continuation_Form_and_Prepayment_Deadlines_2016.pdf)
for specific due dates and associated coverage months.
If you elect to make payments on a monthly basis, it is your responsibility to ensure your payments reach UCSC Payroll
Office by the deadline for each subsequent month.
IF COVERAGE IS CANCELLED
If coverage is cancelled while off pay status, you must submit a completed UPAY 850 form (available on:
ucnet.universityofcalifornia.edu) to the campus Benefits Office to reinstate coverage upon return to pay status. It is
your responsibility to contact the Benefits Office within 31 days upon return pay status to initiate re-enrollment. Your
Period of Initial Eligibility (PIE) period for re-enrollment begins on the day you return to pay status and ends 31 days
later. If the last day of a PIE falls on a weekend or holiday, the PIE is extended to the following business day.
LIFE INSURANCE CONVERSION
Coverage under Basic Life Insurance continues automatically for up to four calendar months. If your non-paid period
lasts longer than the allotted continuation period, you may convert within 31 days to an individual plan. Please contact
the campus Benefits Office for conversion information and forms.
OTHER DEDUCTIONS
For information on other payroll deduction items such as Credit Union, Auto/Home Insurance, etc., contact the
appropriate vendor or office directly. If you have a 403(b) loan, you must contact Fidelity Retirement Services toll free at
(866) 682-7787 to make arrangements for repayment of the loan while off pay status. If you do not take action, the
outstanding amount may be reported as a taxable distribution. It may also be subject to federal and state early
distribution penalties.
Health FSA (Flexible Spending Account) and DepCare FSA (Flexible Spending Account) Participants:
If you are enrolled in the Health FSA and/or DepCare FSA, YOUR PARTICIPATION ENDS AUTOMATICALLY WHEN YOUR
PAY STOPS. Participation ends on the last day of the month of your last contribution. Expenses incurred during months
where no pay is received are ineligible. To re-enroll, you must enroll via paper form (UPAY 850) within 31 days of your
return to work.
Contact the Benefits Office or refer to the Summary Plan Descriptions (available on:
) for more details about the impact of your unpaid leave on these plans.
COBRA
The Consolidated Omnibus Reconciliation Act of 1985 (COBRA) requires the University of California to offer continuation
of University-sponsored medical, dental, optical and/or health flexible spending account (FSA) to qualified employees
and family members enrolled in the plans at the time of certain qualifying events that result in a loss of coverage. If
there is a loss of coverage, you will receive a COBRA election packet and instructions from CONEXIS, UC’s COBRA plan
administrator. If you do not continue your insurance during the non-paid period and terminate employment at the end
of the non-paid period, you will not be eligible for continued coverage under COBRA at the time of termination. You
may contact CONEXIS for COBRA Continuation assistance at 1-(877) 422-2767.
Benefits Bridge 2016 shr-1060 (r.12.2015)
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