Expanded Dependent Life Insurance Plan

Statement of Health Procedure, a.k.a. Evidence of Insurability

Coverage under the UC sponsored Expanded Dependent Life Insurance plans generally starts on the day you become eligible, provided you enroll during your Period of Initial Eligibility (PIE) for yourself and any eligible family members. A Statement of Health is required under the following circumstances:

  1. Apply for employee coverage under the plan after the PIE has ended,
  2. Apply for dependent coverage under the Basic or Expanded Dependent life insurance plans after the PIE has ended,
  3. Increase coverage in the Expanded Dependent Life plan.

A completed Statement of Health is sent to the insurance company for review. Approval is not guaranteed. You will be notified by mail of the insurance company’s decision.

How to Initiate the Process

  1. Complete the Enrollment, Change, Cancellation form (UPAY 850) clearly indicating your Enrollment or Change under the Basic or Expanded Dependent Life Insurance Plans,
  2. Send completed UPAY 850 to Campus Benefits, 200 Wilshire Center, Campus Mail Code: 146548 or by fax: (310) 794-0835

What happens next?

Once a properly completed UPAY 850 form is received by the Central Benefits Office, they will complete the required information in the “Employer Section" of the Statement of Health and send the Statement of Health form to you for completion.

The employee must:

  1. Answer all questions on the Statement of Health. If application is being made for dependent life insurance, be sure to provide information on all family members for whom coverage is being requested, and
  2. Send the completed Statement of Health (employee and employer sections must be completed) directly to:

    The Prudential Insurance Company of America
    Attn: Group Medical Underwriting
    P.O. Box 8796
    Philadelphia, PA 19101
    (Group #97000) (Telephone: 888/257-0412)

How long will the process take?

The review period by the insurance company can take as long as two to three months so you will have to be patient. The insurance company will notify you (and the Central Benefits Office) in writing of their decision. Contact the insurance company if you have any questions regarding the status of your application.

Will I be required to have a physical examination?

No. Initially, the application does not require a medical statement from an attending doctor. During the review process the insurance company may request additional information from your dependent or your physician. Any charges incurred for obtaining this additional information would be the applicant's responsibility. If you are applying for new or increased dependent life insurance coverage amounting to $50,000 or more, it is very likely that Prudential will ask for more information.

When will my request be effective?

If your request is approved, coverage will be effective on the date the Statement of Health was approved, subject to any limitations contained in the contract. The Central Benefits Office will initiate the required change in your payroll deductions. Always review your Sure pay statements or pay stubs to be sure that coverage and your payroll deductions are correctly reflected and notify the Central Benefits Office immediately if there is a discrepancy.

If you have any questions, visit the At Your Service website and click on Health & Insurance, or call the Central Benefits Office at (310) 794-0830.


Campus Human Resources, Benefits Services
Phone: (310) 794-0830 | Fax: (310) 794-0835