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This document is a form used by University of California employees to enroll in, change, cancel, or opt out of health and welfare plans, including insurance and flexible spending account plans. It
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How to fill out enrollment change cancellation or
How to fill out ENROLLMENT, CHANGE, CANCELLATION, OR OPT OUT—EMPLOYEES ONLY
01
Obtain the ENROLLMENT, CHANGE, CANCELLATION, OR OPT OUT form from your HR department or the company portal.
02
Fill out your personal information at the top of the form, including your name, employee ID, and contact information.
03
Indicate the specific action you are requesting: enrollment, change of information, cancellation, or opting out.
04
If enrolling or changing, provide details about the benefits or plans you are enrolling in or altering.
05
For cancellation or opting out, specify the plans you wish to cancel or opt out of and any reasons if required.
06
Review your information for accuracy and completeness.
07
Sign and date the form to confirm your request.
08
Submit the completed form to your HR department by the designated deadline.
Who needs ENROLLMENT, CHANGE, CANCELLATION, OR OPT OUT—EMPLOYEES ONLY?
01
Employees who wish to enroll in, change, cancel, or opt out of any employer-provided benefits or insurance plans.
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What is ENROLLMENT, CHANGE, CANCELLATION, OR OPT OUT—EMPLOYEES ONLY?
ENROLLMENT, CHANGE, CANCELLATION, OR OPT OUT—EMPLOYEES ONLY refers to the processes and forms that employees must complete to enroll in, change, or opt out of company-sponsored benefits or programs.
Who is required to file ENROLLMENT, CHANGE, CANCELLATION, OR OPT OUT—EMPLOYEES ONLY?
All employees who wish to participate in company-provided benefits, or make changes to their current benefit selections, are required to file this form.
How to fill out ENROLLMENT, CHANGE, CANCELLATION, OR OPT OUT—EMPLOYEES ONLY?
To fill out the form, employees should provide personal information, specify the benefits they wish to enroll in or change, and indicate if they are opting out of any benefits. It is important to follow any specific instructions provided with the form.
What is the purpose of ENROLLMENT, CHANGE, CANCELLATION, OR OPT OUT—EMPLOYEES ONLY?
The purpose is to ensure that employees can officially communicate their choices regarding enrollment in, modifications to, or cancellation of benefit programs offered by the employer.
What information must be reported on ENROLLMENT, CHANGE, CANCELLATION, OR OPT OUT—EMPLOYEES ONLY?
Employees must report their full name, employee identification number, choices regarding specific benefits, dates of any changes, and the reason for opting out or making modifications.
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