Plan Documents and Forms

2024–2025 Benefit Year Documents

2024 UCD Benefits Brochure [PDF]

2024 UCSD Benefits Brochure [PDF]

2024 UCSF Benefits Brochure [PDF]

2024 UCLA Benefits Brochure [PDF]

2024 UCI Benefits Brochure [PDF]

2024 UCR Benefits Brochure [PDF]

2023–2024 Benefit Year Documents

Delta Dental Benefits Summary

2024 FSA Summary Plan Description

2023 Anthem HMO Medical Plan Benefits Summary [PDF]

2023 Anthem HMO SBC [PDF]

2023 Anthem HMO SPD [PDF]

2023 Anthem PPO Medical Plan Benefits Summary [PDF]

2023 Anthem PPO SBC [PDF]

2023 Anthem PPO SPD [PDF]

2023 FSA Summary Plan Description [PDF]

2023 New York Life AD&D (Non-U.S. Citizen) Benefit Summary [PDF]

2023 New York Life AD&D (U.S. Citizen) Benefit Summary [PDF]

2023 New York Life Life Insurance (Non-U.S. Citizen) Benefit Summary [PDF]

2023 New York Life Life Insurance (U.S. Citizen) Benefit Summary [PDF]

2023 New York Life Long-Term Disability (Non-U.S. Citizen) Benefit Summary [PDF]

2023 New York Life Long-Term Disability (U.S. Citizen) Benefit Summary [PDF]

2023 New York Life Short-Term Disability (Non-U.S. Citizen) Benefit Summary [PDF]

2023 New York Life Short-Term Disability (U.S. Citizen) Benefit Summary [PDF]

2023 VSP Benefits Summary [PDF]

Family Forming

Carrot Elective Fertility Benefits

HRA Plan Document

HRA Summary Plan Description (SPD)

Fertility Plan Document

Adoption Plan Document

Surrogacy and Gestational Plan Document

Forms

2022 Long Term Disability Conversion Form

Delta Dental Claim Form

New York Life AD&D Beneficiary Form

New York Life AD&D Claim Form

New York Life Group Benefits Claim Form

New York Life How to File a Disability Claim Brochure

New York Life How to File a Life or AD&D Insurance Claim Brochure

New York Life Life Insurance Beneficiary Form

New York Life Life Insurance Claim Form

New York Life Long-Term Disability Claim Form

New York Life Short-Term Disability Claim Form