Statement of Health Application and Enrollment Instructions

Home / Campus and Medical Center / ( Published on 2014-05-19 )

  • To apply for or increase your coverage in the Supplemental Life Plan or to enroll eligible dependents in the Basic Dependent Life or Expanded Dependent Life Plans outside of a Period of Initial Eligibility (PIE), follow the instructions on UCnet.
  • To apply for Supplemental Disability coverage outside of a PIE or to shorten your current disability waiting period, follow the instructions below:

Supplemental Disability Statement of Health Application

1. Complete and send an Evidence of Insurability Form directly to Liberty Life Assurance Company of Boston.  Liberty, the insurance carrier, will review the medical information you provide on the questionnaire to determine whether or not to accept your enrollment. During the review process Liberty may ask you or your physician for additional information. Any charges incurred for obtaining this additional information is your responsibility. The review period may take up to 60 days.

Liberty Life Assurance Company of Boston 
ATTN: Group Underwriting Dept 
100 Liberty Way 
P.O. Box 1525 
Dover, NH 03821-1525
Group # 60-037972 
Telephone: 800-210-0268, ext 58481

2. When the review has been completed, Liberty will mail a letter to your home address notifying you of the decision. If approved, complete the following sections of the Enrollment, Change, Cancellation form (UPAY 850) and send the form along with your approval letter to Payroll, via e-fax 415-920-2512, [email protected], or Box 0812, within 31 days of the approval date on the letter. The effective date of the change will be the approval date listed on your letter.

Instructions for 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

Always review your earnings statement each month to ensure that your coverages and any changes made are reflected accurately.