Upay850 2026

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4.4 out of 5

128 votes

The document provides instructions for University of California employees regarding enrollment, changes, cancellations, or opting out of health and welfare plans, including the Health Savings Plan and Flexible Spending Accounts (FSA). It outlines eligibility criteria, necessary actions to take for various life events (such as marriage or loss of coverage), and details on how to manage contributions to Health Savings Accounts. Additionally, it emphasizes the importance of timely notifications for changes in family member eligibility and includes privacy notifications related to personal information.

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Click ‘Get Form’ to open the upay850 in the editor.
Begin by completing Section 1, ‘Personal Information.’ Fill in your name, employee ID number, home address, work email address, and daytime phone number.
If you wish to opt out of coverage, complete Section 2. Check the relevant boxes for the plans you are declining and provide a reason for opting out.
In Section 3, indicate your actions by checking all applicable boxes. If enrolling or canceling coverage, follow the instructions to complete Sections 4 through 8 as needed.
For medical, dental, and vision plans in Section 4, mark ‘Enroll’ or ‘Cancel’ as appropriate. Ensure you also enter any contributions for Health Savings Accounts in this section.
Complete Section 7 if you need to enroll or de-enroll eligible family members. Provide their details and select the appropriate insurance plan boxes.
Finally, sign and date Section 8 to confirm that all information is accurate and that you understand the terms of enrollment.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (181 Votes)
2017	4.4 Satisfied (128 Votes)
2005	4.4 Satisfied (248 Votes)

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