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UUP BTF Change of Marital or Dependent Status

Please fill out the form below to electronically submit a Change of Marital or Dependent Status form to the UUP Benefit Trust Fund.

To enroll and complete a paper enrollment form HERE and you may email, fax or mail to the UUP Benefit Trust Fund.

Fax: 1-866-559-0516 Mail: Benefit Trust Fund , PO Box 15143, Albany, NY 12212-9954 Email: Benefits@uupmail.org

A copy of a valid marriage certificate or birth certificate is required to be sent to the UUP Benefit Trust Fund before the form can be processed (see “attach a file” below). Any documents that need to be sent at a later date can be sent to benefits@uupmail.org.

Employee Information:

*First name:
Middle:
*Last name:
*Date of Birth:
*NYS Employee ID:
*Address:
*City:
*State:
*Zip Code:
*Non-SUNY Email:
*Home/Cell:
*Work:

*Required

Marital Status Change:

I am married

I am divorced

I am widowed

Spouse Information

First name:
Middle:
Last name:
Date of Birth:
Gender:
Date of Event:

Domestic Partner Change

Domestic partner information must be provided to the campus HBA for eligibility verification. The Fund cannot enroll domestic partners until confirmation has been received from the NYS Dept. of Civil Service. Please call the Fund if your domestic partner wants dental and vision coverage (and does not want medical coverage).

Add

Delete

First name:
Middle:
Last name:
Date of Birth:
Gender:
Date of Event:

Name Change

New Name:

First name:

Middle:

Last name:

Former Name:

First name:

Middle:

Last name:

Change of Dependents

DEPENDENT #1

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #2

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #3

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #4

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #5

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #6

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

Enter Additional Dependent Children:

(HERE)

DEPENDENT #7

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #8

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #9

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #10

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #11

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

DEPENDENT #12

Add Delete

First name:
Last name:
Middle:
Gender:
Date of Birth:

ATTACH A FILE:

*Acceptance of Terms

YES! I Agree that submission of this form constitutes my consent to online marital or dependent status changes. You will receive an email confirming receipt of this form. Please retain a copy of that email for your records.

* Required

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P.O. Box 15143 Albany, NY 12212-9954
1-800-342-4206
1-866-812-9446
comment@uupmail.org

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