LATE ENROLLMENT REQUEST FORM
The retention schedule for this form can be found at http://recordsretention.ucop.edu/.
Page 1 of 2
The Late Enrollment Request form is for employees who need to enroll in benefit plans once they have missed the open
enrollment period (OEP) or period of initial eligibility (PIE), or for Faculty second PIE. Click to access form instructions.
SECTION 1. KEY INFORMATION *Indicates Required Fields
Date Submitted* (m/d/yyyy)
(numbers only; no spaces)
SECTION 2. QUALIFYING EVENT INFORMATION*
Check all that apply. Write in date of event, if applicable.
Event Date (m/d/yyyy)
Involuntary Loss of Coverage
Return from Leave
Change in Appointment Status
Divorce/Separation/Termination of Domestic Partnership
Other (please explain below)
SECTION 3. REASON FOR LATE ENROLLMENT REQUEST*
Please indicate the reason you are requesting late enrollment.
SECTION 4. 90-DAY WAITING PERIOD FOR MEDICAL OPTION*
Per UC Policy, an employee who is not enrolled in any medical plan because a Period of Initial Eligibility (PIE) or Open
Enrollment Period (OEP) was missed may enroll in a No TIP (after-tax) medical plan subject to a 90-day waiting period.
If your late enrollment request is denied, do you want to be enrolled in a medical plan subject to the 90-day
Yes, I would like to be enrolled in the 90-day waiting period for the medical option.
No, I want to decline medical coverage.