Employee Benefits Change Form

UUA Insurance Benefits Change Form

NOTE: Insurance Plans invoices close on the 15th of each month. Changes submitted after the 15th will be reflected on the following months insurance plan invoice.

Use this form to report changes/transitions for employees enrolled in the UUA Insurance Plans or Retirement Plan. Changes must be reported directly to the Office of Church Staff Finances using this form. Never send Insurance or Retirement Plan changes with payments. The Insurance Plans bank lock box and Retirement Plan recordkeeper staff cannot report your changes to us.

Please use one form per employee; multiple changes for one employee can be reported on one form. Use this form to report:
- Employee status changes - reduction in hours, termination/retirement or transition to new congregation
- Employee income updates (affects Life/Accidental Death & Dismemberment Insurances (AD&D) and Long-Term Disability Insurance (LTD) coverage) For the Retirement Plan, you must re-calculate contribution amounts due
- Employee address changes (can affect Health premiums)
- For the Retirement Plan, changes must also be submitted using the Empdata Online Submission Form. Please contact retirementplan@uua.org with questions
- Employee Elective Drop of coverage for self or dependents
- Employee Elective plan level change
- Employee Name Change
- Employee Death
Congregation ID/Account Number*
Employee's Name (legal name)*

First NameLast Name
Employee's Email*
Employee's Phone Number*

Area CodePhone Number
Employee's Occupation or Job Title*
Effective date of change*

MonthDayYear
Request Type:*

Benefit TransitionEmployment TerminationBenefit(s) Only TerminationSalary Change OnlyAddress Change OnlyHealth Insurance Plan Level ChangeName Change Only

Employment Termination
Employment termination will discontinue the members benefits, are you sure you wish to proceed?*

YesNo
Reason for termination?*

Voluntary TerminationTerminatedFurloughLaid Off/Position EliminatedRetirementDeath
What is the benefit date of termination?*

MonthDayYear
*Changes older than 60 days cannot be processed
Special Considerations

Salary Change
New Annual Salary (salary plus housing for Ministers)*
Would you also like to update your home (mailing) address?*

NoYes
New Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Special Considerations

Address Change
New Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you also like to update your Salary?*

NoYes
New Annual Salary (salary plus housing for Ministers)
Special Considerations

Health Insurance Plan Change
Health Insurance Plan Change

Use this form if you are already enrolled in the UUA Health Plan and want to change your plan to a lower cost, higher deductible plan at any time. If you are looking to change to a higher cost, lower deductible plan, this option is only available during Open Enrollment. Please check with your Administrator or Treasurer to be sure the plan you want is offered by your employer and reflected on their Health Plan Subscription Agreement. If you are adding dependents to the Health or Dental plan, you must use the Benefit Enrollment Form. There is NO Open Enrollment for Life or LTD Insurance. NOTE: Changes to a lower cost, higher deductible plan can be made at any time during the year. Change to a higher cost, lower deductible plan can be made only during Open Enrollment each November. The deadline for Open Enrollment changes is November 30 each year. All Open Enrollment changes will be effective January 1.
Choose a Health Plan:*

Standard PPO PlanHigh Deductible Plan w/HSAHigh Deductible Plan without HSABronze Plan w/HSABronze Plan without HSAMedicare Complementary Plan
Please upload the Medicare Waiver Form and Medicare Card*

Cancelof

Name Change
Name Change

First NameLast Name

Retirement Plan Information
RETIREMENT PLAN
If you are making changes for an employee enrolled in the UUA Retirement Plan, please also complete this section and the Empdata Online Submission Form. Please contact retirementplan@uua.org with questions.
Date of Hire

MonthDayYear
End of Service Date

MonthDayYear
Reason for Ending Service

Voluntary TerminationLaid OffTerminated for CauseFurloughRetirementDeath
Date Final Contributions were sent to Empower for this employee

MonthDayYear

Prior Congregation Details

New Congregation Details

Benefit Selection(s)

Retirement Plan

Health Insurance Plan Change

RETIREMENT PLAN