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Get CA UBEN 100 2012

His form, call the UC Customer Service Center (1-800-888-8267) or your location’s Health Care Facilitator; for the contact list, visit: atyourservice.ucop.edu/directories_contacts/health_care_facilitator.html 1. PERSONAL INFORMATION—retiree, survivor or disabled member NAME (Last, First, Middle Initial) SOCIAL SECURITY NUMBER FORMER CAMPUS/LAB LOCATION RETIREMENT SYSTEM COVERAGE CalPERS ADDRESS (Number, Street) NEW (City, State, ZIP) UCRP OTHER (Specify): EMAIL ADDRESS NEW .

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