Insurance Continuation Form - For Post Doctoral Scholars On Leave Without Pay Page 3
Download a blank fillable Insurance Continuation Form - For Post Doctoral Scholars On Leave Without Pay in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Insurance Continuation Form - For Post Doctoral Scholars On Leave Without Pay with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3SPECIAL CONDITIONS FOR CONTINUED UC CONTRIBUTIONS - In order to receive these special University contributions, you
must complete and return the attached Insurance Continuation Form (ICF).
•
Short Term Disability Benefits: The University will continue to make contributions to medical insurance for up to six
months during a LWOP if you are receiving Short Term Disability benefits through The Standard. If your disability
benefits cease, and you continue to be on LWOP, you may continue your medical insurance by paying the full
premium.
o If you are eligible for special medical coverage because of receipt of Short-Term Disability benefits, you should
write in and pay the employee deduction amount.
Contact UC’s Post Doctoral Scholar Benefit Plan
Administrator, Garnett Powers & Associates, at 1-800-254-1758 for disability eligibility information and
processes.
•
Family Medical Leave Act/California Family Rights Act (FMLA/CFRA) Under FMLA/CFRA, the University will make
contributions to medical, dental and optical insurance for up to 12 workweeks in a 12-month period while you are on
LWOP. If your FMLA and/or CFRA entitlements end and you continue to be on LWOP, you may continue your medical,
dental and optical coverage by paying the total premium. If you are concurrently eligible for FMLA and Short Term
Disability benefits, you may be eligible to continue receiving the University contribution for medical insurance
premiums for up to a maximum of six months while disabled. If you are concurrently eligible under FMLA and
Pregnancy Disability Leave (PDL), usually 8 workweeks, you may be eligible to continue to have University
contributions to medical, dental and optical under CFRA for parental leave/bonding for up to an additional 12
workweeks following the end of PDL. Contact your academic HR coordinator for FMLA/CFRA eligibility information.
o If you are eligible for special medical, dental and optical plan contributions because of FMLA/CFRA benefits,
you should write in and pay the employee deduction amount (no premiums are due for dental or vision, if
eligible for FMLA/CFRA).
•
Pregnancy Disabililty Leave Law (PDLL): Employers maintain and pay for health care insurance (medical, dental and
optical) coverage for an employee on pregnancy disability leave for a period not to exceed four months over the
course of a 12-month period. This provision applies even for employees not otherwise eligible for FMLA or Short Term
Disability Benefits. PDLL runs concurrent with FMLA and pregnancy disability.
o If you are eligible for special medical, dental and optical plan contributions because of the PDLL provision,
write in and pay the employee deduction amount.
IF COVERAGE IS CANCELLED
If coverage is cancelled, you must submit a completed enrollment form (available on-line:
) 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 work or 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.
403b LOAN REPAYMENT
If you have a 403(b) loan, you must contact Fidelity Retirement Services at 1-866-682-7787 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.
COBRA
The Consolidated Omnibus Reconciliation Act of 1985 (COBRA) requires UC’s Post Doctoral Scholar Benefit Plan Administrator,
Garnett Powers & Associates, to offer continuation of University sponsored medical, dental and optical insurance to qualified
Post Doc’s and family members enrolled in the plans at the time of certain qualifying events. If you separate from employment
at the end of the leave period, you may be eligible for COBRA continuation of coverage. If you do not continue your insurance
during your leave period, you will not be eligible for continued coverage under COBRA at the time of separation. If you wish to
request a COBRA continuation election form or need assistance, please call UC’s Post Doctoral Scholar Benefit Plan
Administrator, Garnett Powers & Associates, at 1-800-254-1758.
_______________________________________________________________________________________________________
PSBP LWOP 2016 shr-1030PSBP (r. 12.2015)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Et-81 - Application Form For Refund Of Taxes On Beer Or Malt Beverages Paid In Excess Of Legal Requirements
Financial
Form Alc-81 - Application Form For Refund Of Taxes On Beer Or Malt Beverages Paid In Excess Of Legal Requirements
Financial
Related Categories
Parent category: Legal