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Separation – Benefits Checklist


Action Date

Preparer Initials

Benefits – Refer to EDB Manual B12.0    
Termination of Employment Checklist    
Health and Welfare Plans  
COBRA - Notification from CONEXIS 24 weeks from separation function in EDB (Automatically generated when separation function is performed)  
COBRA Premium Rates and Insurance carrier address information  
COBRA Notice    
HealthCare/DepCare Reimbursement Account
COBRA continuation (for HCRA only)
AD&D Conversion
Provide the conversion application and direct employee to AIG Benefit Solutions at 800-551-0824
Basic/Supplemental Life Conversion
Print out Conversion Form in Related Information
Must complete and sign form before handing it to employee
Supplemental Life/Expanded Dependent Life Portability
Direct employees to Welfare Plans in Related Information
Legal Plan Conversion
Direct employee to ARAG Plan in Related Information
Retirement Plans    
UC Retirement Savings Program (DCP, 403(b), 457(b) plan) for
distributions and/or future inquiries direct employee to the Fidelity Retirement Services website in Related Information.
CAP – Distribution Request UBEN142 CAP (R4/14)
Direct employee to automated request system on UCnet (At Your Service) following a separation of 30 days or more
Refund of Accumulations UCRP
Following a break in service of 30 days or more, direct employee to UCnet (At Your Service). See Related Information.
UCRP Pension Benefits Estimates
Direct employee to UCnet (At Your Service). See Related Information.


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