Fillable LATE ENROLLMENT REQUEST FORM SECTION 1. KEY INFORMATION

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LATE ENROLLMENT REQUEST FORM SECTION 1. KEY INFORMATION

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  • 14 check-boxes
  • 39 other fields

Country of origin: US
File type: PDF

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LATE ENROLLMENT REQUEST FORM
The retention schedule for this form can be found at http://recordsretention.ucop.edu/.
R
evised: 10/23/2017
Page 1 of 2
FR.006
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
Employee ID #*
(8 Digits)
Last Name*
First Name*
M.I.
Submitter’s Name*
Date Submitted* (m/d/yyyy)
Submitter’s Phone*
(numbers only; no spaces)
Submitter’s Email*
SECTION 2. QUALIFYING EVENT INFORMATION*
Check all that apply. Write in date of event, if applicable.
Event Date (m/d/yyyy)
Hire/Rehire
Open Enrollment
Birth/Adoption
Involuntary Loss of Coverage
Return from Leave
Change in Appointment Status
Marriage/Domestic Partnership
Divorce/Separation/Termination of Domestic Partnership
Retroactive Appointment
Faculty 2
nd
PIE
Other (please explain below)
SECTION 3. REASON FOR LATE ENROLLMENT REQUEST*
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
waiting period?
Yes, I would like to be enrolled in the 90-day waiting period for the medical option.
No, I want to decline medical coverage.
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LATE ENROLLMENT REQUEST FORM
FR.006
The retention schedule for this form can be found at http://recordsretention.ucop.edu/.
Revised: 10/23/2017
Page 2 of 2
SECTION 5. EMPLOYEE SIGNATURE
Employee Signature* Date* (m/d/yyyy)
SECTION 6. UCPATH INTERNAL USE ONLY
Request Approved
Approver Name Approval Date (m/d/yyyy)
Approver’s Signature
Additional UCOP Approval Required
Approver Name Date Forwarded (m/d/yyyy)
Approver’s Signature
Request Denied
Authorized Name
Reason Code
Authorized Signature Date Denied (m/d/yyyy)
(Employee Signature will lock all previous fields on form.)
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LATE ENROLLMENT REQUEST FORM SECTION 1. KEY INFORMATION

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Completed 8 December 2020

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