ENROLLMENT, CHANGE, CANCELLATION, OR OPT OUT EMPLOYEES ONLY HEALTH AND WELFARE PLANS UPAY 850 (R10/13) University of California Human Resources INSTRUCTIONS Blue Shield Health Savings Plan Use this.
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How to fill out the Upay850 online
This guide provides step-by-step instructions on how to accurately fill out the Upay850 form online for enrolling, changing, or cancelling your health and welfare benefits at the University of California. Our objective is to make the process straightforward and accessible for all users.
Follow the steps to complete the Upay850 form efficiently.
- Press the 'Get Form' button to access the Upay850 document and open it in the relevant editor.
- In Section 1, enter your personal information including your full name, employee ID number, home address, work email address, and daytime phone number.
- If opting out of coverage, navigate to Section 2 and check the plans you wish to decline, providing the reason for your choice.
- Move to Section 3 to indicate the action you are taking. Check the appropriate box for enrolling, cancelling, or making a change, and include relevant dates for any life events.
- In Section 4, select the plans you want to enroll in or change. If cancelling a plan, be sure to check the cancel box for your current plan.
- Complete Section 5 if opting for additional insurance plans, marking your preferences clearly.
- In Section 6, enter the dollar amounts for your Health Flexible Spending Account (FSA) and Dependent Care FSA, if applicable.
- Fill in Section 7 to enroll or change information for eligible family members, utilizing the correct relationship codes.
- Finally, sign and date Section 8 to confirm that all the provided information is accurate and that you understand the terms and conditions.
Complete your Upay850 form online today to ensure you receive the benefits you deserve.
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