Statement-of-Health Application and Enrollment Instructions
How to apply for increased life/disability coverage outside of a Period of Initial Eligibility. Life and disability insurance is never an Open Enrollment option.
Note for UCSF Medical Center employees: Please call 415/353-4545 for Medical Center Human Resources/Benefits applicationprocedures.
Follow these instructions:
- If applying to enroll in Supplemental Disability coverage outside of a PIE (Period of Initial Eligibility), or to shorten your current disability waiting period, OR
- If applying to enroll or increase coverage in the Supplemental Life plan or to enroll eligible dependents in the Basic Dependent Life or Expanded Dependent life plans.
APPLICATION
A. Contact your Department Benefits Representative for the enrollment form or click, download, and complete the Enrollment, Change, Cancellation form (UPAY 850).
Please clearly indicate on the form:
- The Type of Action as "Statement-of-Health";
- The plan(s) and level of insurance being requested;
- Your Campus mailing address/box number.
Sign and send the completed enrollment form to:
UCSF Human Resources/Benefits Office
3333 California Street, Suite 330
San Francisco, CA 94143-0918
Campus Mail: Box 0918, LHts 330
Note for UCSF Medical Center employees: Please call 415/353-4545 for Medical Center Human Resources/Benefits claims procedures.
Benefits Office staff will issue appropriate statement-of-health questionnaire, certifying "Employer Section" based on insurance and levels of coverage requested.
B. Answer all questions on the statement-of-health. If you are applying for dependent life coverage, be sure to provide information on all family members for whom coverage is being requested.
C. Send the completed statement-of-health directly to the appropriate insurance carrier. (See Insurance Carrier Information listed below.)
REVIEW
Initially your application does not require a medical statement from your doctor. The insurance carrier reviews the medical information you provide on the questionnaire to determine whether or not to accept your enrollment. During the review process the carrier may ask you or your physician for additional information. Any charges incurred for obtaining this additional information would be the applicant’s responsibility. If you are applying for new or increased life insurance coverage amounting to $50,000 or more, it is very likely that Prudential will ask for more information. The review period may take up to two or three months. The carrier will notify you (and the Payroll Office) in writing of the decision. Contact the insurance carrier should you have any questions regarding the status of your application--see below for phone numbers.
ENROLLMENT/EFFECTIVE DATE
Once application/review is complete and enrollment is approved coverage will be effective on the Statement of Health approval date. Always review your earnings statements or paystubs to ensure that proper coverage is reflected.
Disability Insurance Plan carried by Liberty Mutual
If applying to enroll in Supplemental Disability coverage outside of a PIE (Period of Initial Eligibility), or to shorten your current waiting period, send completed statement-of-health to:
Liberty Mutual Insurance Company
ATTN: Medical Underwriting
P.O. Box 1525
Dover, NH 03821-9901
(Group # 037972)
(Telephone: 800/210-0268, ext 58481)
Life Insurance Plans carried by Prudential
If applying to enroll or increase coverage in the Supplemental Life plan or to enroll eligible dependents in the Basic Dependent Life or Expanded Dependent life plans, send completed statement-of-health directly to:
The Prudential Insurance Company of America
Group Medical Underwriting
P.O.Box 8796
Philadelphia, PA 19101
(Group #97000)
(Telephone: 888/257-0412)