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How to fill out the CA UBEN 100 online
Completing the CA UBEN 100 online is a crucial step for retirees, survivors, or disabled members seeking medical, dental, and legal plan benefits through the University of California. This guide is designed to help you navigate each section of the form with ease and confidence.
Follow the steps to effectively fill out the CA UBEN 100 online
- Select the ‘Get Form’ button to obtain the CA UBEN 100 form and open it in your online editor.
- In the first section, 'Personal Information,' fill in your name (last, first, middle initial), social security number, former campus location, retirement system coverage, and your complete address, including city, state, and ZIP code.
- Provide your email address, ensuring that you can change it through the specified online service.
- In the second section, 'Actions,' select the appropriate action for your situation, whether you are enrolling, changing, or canceling a plan. Include necessary details such as marriage date or divorce date if relevant.
- Complete the 'Medicare' section by entering the effective dates for Medicare Parts A and B, and include the Medicare claim number if applicable.
- In the 'Medical, Dental, and Legal' section, indicate your choice of plans by checking the appropriate boxes under medical, dental, or legal plans.
- In the 'Enrollee Information' section, list yourself and any eligible family members, entering the required relationship codes and relevant personal details.
- Finally, review your entries, sign the form, and note the date. You can save changes, download, print, or share the completed CA UBEN 100.
Start filling out your CA UBEN 100 online today to ensure your continued access to vital benefits.
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