Statement-of-Health Application and Enrollment Instructions
Note for UCSF Medical Center employees: Please call 415/353-4545 for Medical Center Human Resources/Benefits application procedures.
- To apply for Supplemental Disability coverage outside of a PIE (Period of Initial Eligibility), or to shorten your current disability waiting period, follow the instructions below
- To apply for or increase coverage in the Supplemental Life Plan or to enroll eligible dependents in the Basic Dependent Life or Expanded Dependent Life Plans, follow the instructions on the At Your Service website
SUPPLEMENTAL DISABILITY APPLICATION
A. Complete the following sections of the Enrollment, Change, Cancellation form (UPAY 850).
- Section 1: Complete Personal Information
- Section 3: EMPLOYEE ACTIONS:
- If enrolling – Go to ‘Enroll’ column and check box “Other”
- If changing Waiting Period – Go to ‘Change’ column and check third box “Disability Waiting Period”.
- Under “comment box”, please specify type of action (i.e. Enroll to Supplemental Disability or shorten current waiting period with Statement of Health Application)
- Section 5: Check appropriate boxes
- Section 8: Sign and date form
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
FAX: 476-2328
The Benefits Office will send you the statement-of-health questionnaire and will forward the UPAY 850 to the Payroll Office.
B. Send the completed statement-of-health application directly to Liberty Life Assurance Company of Boston
Liberty Life Assurance Company of Boston
ATTN: Group Underwriting Dept
P.O. Box 1525
Dover, NH 03821-9901
Group # 037972
Telephone: 800/210-0268, ext 58481
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. The review period may take up to 60 days. 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.
ENROLLMENT/EFFECTIVE DATE
Once application/review is complete and enrollment is approved, the plan will send an approval letter to the payroll office and a copy to you. The coverage will be effective based on the date of the approval letter. You may want to contact payroll directly once you receive your letter to ensure they are processing your new coverage. Always review your earnings statements or paystubs to ensure that proper coverage is reflected.