Get Continuecancel

This guide provides a comprehensive overview of how to effectively fill out the Continuecancel form for university coverage. By following the outlined steps, you will ensure that your insurance benefits are appropriately maintained or canceled during your leave without pay.

Follow the steps to successfully complete the Continuecancel form.

1. Click ‘Get Form’ button to access the form and open it in the online editing interface.
2. Begin by entering your name in the designated field labeled 'EMPLOYEE NAME'.
3. Input your employee number in the corresponding section titled 'EMPLOYEE #'.
4. Provide your temporary address while on leave in the 'ADDRESS WHILE ON LEAVE' section.
5. Enter a valid telephone number and email address where you can be reached during your leave in the respective fields.
6. Specify the department you are associated with by filling in the 'DEPT/CONTACT' area along with the appropriate department phone number and email.
7. Indicate the dates of your leave by filling in the 'DATES OF LEAVE' fields, marking the start and end dates.
8. Check all applicable options regarding the types of leave you are experiencing from the list provided.
9. Choose one of the options provided for either canceling or continuing your benefits during your leave.
10. If continuing benefits, mark the plans you wish to continue and fill in the corresponding premium amounts for both UC and employee contributions.
11. Specify the months for which your payments will cover by checking the appropriate boxes.
12. Include the total amount of your payment in the designated field and ensure your check or money order is attached, made payable to 'UC Regents'.
13. Review your information for accuracy, then sign and date the form at the bottom.
14. Submit the completed form along with your payment to the Payroll – Benefits Accounting Unit at the provided address.

Complete your Continuecancel document online today to ensure your insurance coverage is correctly handled during your leave.