Insurance Continuation Form - For Post Doctoral Scholars On Leave Without Pay

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2016 UCSC INSURANCE CONTINUATION FORM (ICF)
FOR POST DOCTORAL SCHOLARS ON LEAVE WITHOUT PAY (LWOP)
When you are on Leave Without Pay, you must take immediate action in order to continue or cancel your University insurance.
IMPORTANT NOTICE: Failure to complete and return this 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. 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-1030-
PSBP.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 for the following month’s coverage. For example, if your pay stops Feb 1
st
,
payments for March coverage are due February 10
th
.
Post Doctoral Scholar Employee Information and Continuation/Cancellation Elections:
Name: __________________________________________
Employee ID#: ___________________________
E-mail Address (Personal Preferred): _________________________________________________
_________
Home Address: ________________________________________________________________________________
Primary Phone: ___________________________________
Unit: _________________________________
Period of Leave without Pay: From: _____ /________ /______ To: _______ /_______ /_______
Special Leave Types [Mark any that apply - See Special Conditions Section of Instructions]:
FML/ CFRA: ___ Pregnancy Leave: ___ Workers’ Comp.: ___ Short-term Disability/The Standard: ___
Monthly
# Months
Total Premium
Payroll
Insurance Plan
Continue
-OR-
Cancel
Premium Owed
Covered
Enclosed
Use
Medical: _______________
( )
( )
$_____________
# ______
$_____________
____________
Dental: ________________
( )
( )
$_____________
# ______
$_____________
____________
Vision PPO
( )
( )
$_____________
# ______
$_____________
____________
Life/AD&D
( )
( )
$_____________
# ______
$_____________
____________
____________
Total Premium Enclosed:
$_____________
Enclosed is my check/money order in the amount of $___________ made payable to “UC Regents” for the following
earnings & coverage month(s) [Coverage is paid for a month in advance – see instructions] 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.
_____________________________________________________
_________________
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!
PSBP LWOP 2016 shr-1030PSBP (r. 12.2015)

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