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UCB Cares Program Enrollment Form

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2018-2019 HWM Graduate Dependent Enrollment Form

PLEASE SEE OTHER SIDE FOR RATES AND PAYMENT INFORMATION. YOU MUST COMPLETE BOTH SIDES OF THIS ENROLLMENT FORM.

Student’s Name

U.S. Mailing Address (Use school address if none)

Please select the gender you identify as:

Please check appropriate box:

Please check appropriate box:

PLEASE LIST DEPENDENTS TO BE INSURED BELOW. DEPENDENT COVERAGE IS AVAILABLE ONLY IF THE STUDENT IS ALSO ENROLLED IN SHIP. Please see the Benefit Booklet for complete benefits and contact information. Dependents must be enrolled on the date the student is enrolled or within 31 days of a qualifying event.

Last / Surname
First Name
Middle Initial
Gender
Date of Birth
(Month, Day, Year)
Social Security or Tax I.D. #
(U.S. Citizens and Permanent Residents only)

Spouse/Domestic Partner:

Child:

Child:

Child:

Child:

Required Documentation for Dependent Enrollments (Must Attach and Mail with This Enrollment Form, or bring to the ship office):

a) For spouse, a marriage certificate

b) For same-sex/opposite-sex domestic partner, a Declaration of Domestic Partnership issued by the State of California, or of same-sex legal union other than marriage formed in another jurisdiction, or a completed Declaration of Domestic Partnership form issued by University Health Services

c) For natural child, a birth certificate showing the student is the parent of the child

d) For stepchild, a birth certificate, and a marriage certificate showing that one of the parents listed on the birth certificate is married to the student

e) For adopted or foster child, documentation from the placement agency showing that the student has the legal right to control the child’s health care

Anthem Blue Cross Life and Health Insurance Company

Berkeley SHIP

www.anthem.com/ca/ucberkeley

Berkeley SHIP Office

Benefits and General Questions

510-642-5700

On Call International

International Travel Assistance

877-318-6901

PAYMENT IN FULL IS REQUIRED FOR THE TERM PURCHASED

COVERAGE IS NOT AUTOMATICALLY RENEWED. Coverage will end on the last date specified in the plan you select, unless you enroll to continue insurance for an additional term. Premiums are calculated based on the plan term and will not be pro-rated.

PLEASE READ CAREFULLY AND SIGN BELOW - REQUIREMENT FOR BINDING ARBITRATION

I attest by signing below that I have reviewed the information provided on this application and to the best of my knowledge and belief, it is true and accurate with no omissions or misstatements and I have read and understand the Plan Brochure.

PAYMENT METHOD (Remit in US Funds Only)

NOTE: If we are unable to process your payment (due to insufficient funds, closure of account, etc.), you and/or your dependents’ insurance coverage will be terminated retroactive to the effective date of the enrolled term and you will be responsible for any claims that you’ve incurred.

(Enter/Print Cardholder’s name exactly as it appears on card.)

Send enrollment form, dependent documentation, and payment by mail, email or fax to: USI Student Insurance, 10940 White Rock Road, 2nd Floor, Rancho Cordova, CA 95670 • sienrollment@usi.com • Fax (877) 612-7966

Program Costs

Fall
8/1/18 - 12/31/18
Spring/Summer
1/1/19 - 7/31/19
Enrollment Deadline
9/15/18
2/1/19
NOTE: Costs below are in addition to the student premium. Dependent enrollment in this plan is voluntary.
Spouse only
$2,373.00
$2,373.00
1 Child only
$2,373.00
$2,373.00
2 Children only
$4,615.00
$4,615.00
3 Children only
$4,648.00
$4,648.00
4 Children only
$4,681.00
$4,681.00
5 Children only
$4,714.00
$4,714.00

USI Insurance Services Privacy Information

We know that your privacy is important to you and we strive to protect the confidentiality of your personal information. We do not disclose any personal information about our plan participants, except as permitted or required by law.

You may obtain a detailed copy of our privacy policy through your school or by calling us at (800) 853-5899 or by visiting us at http://www.usi.com/privacy.

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What the UCB Cares Program Enrollment Form Is

The UCB Cares Program Enrollment Form is a structured intake document used to register individuals or households for assistance, benefits, or services administered under the UCB Cares initiative. It collects identifying information, contact details, eligibility indicators, consent to share limited data with program partners, and signature authorization to confirm applicant intent. The form is commonly used by program administrators, social service coordinators, and benefits managers to standardize enrollment, document consent, and establish an audit trail for eligibility decisions and follow-up communications.

Why a Complete Enrollment Form Matters

A fully completed enrollment form reduces processing delays, ensures consistent eligibility determinations, and creates a retrievable record for audits or appeals. Accurate forms protect applicant rights and help administrators meet reporting, retention, and confidentiality obligations.

Why a Complete Enrollment Form Matters

Who Completes and Who Receives the Form

Maintain copies of signed forms within the case file and log access to comply with privacy and retention rules.

  • Applicants or legal guardians completing personal and eligibility fields for benefits or support
  • Program intake staff verifying documentation, uploading supporting files, and setting case status
  • Partner agencies receiving consented data for coordinated services and referral tracking

Step-by-Step: Completing the Enrollment Form

Follow these steps to complete and submit the UCB Cares Program Enrollment Form without common errors.

  • 01
    Step 1: Gather ID and supporting documents before starting the form.
  • 02
    Step 2: Enter personal and contact details using the specified formats.
  • 03
    Step 3: Upload required attachments and confirm file legibility.
  • 04
    Step 4: Review all entries, sign, date, and submit for intake processing.

Typical Submission and Processing Flow

This outlines how a completed form moves from applicant submission to case resolution.

  • Submit: Applicant submits form online or in person with attachments.
  • Verify: Intake team checks identity, eligibility, and documents.
  • Approve or Refer: Determine eligibility, approve benefits, or refer to partner services.
  • Record: Store signed form in case file and capture audit trail.

Essential Elements of a Professional Enrollment Form

A well-designed form balances clarity, compliance, and administrative efficiency to support accurate intake and downstream casework.

Clear Identifiers

Fields for full legal name, alternate names, date of birth, and unique program ID reduce mismatches and simplify record linking across systems.

Eligibility Checklist

Structured yes/no and multiple-choice fields capture program-specific qualifiers, minimizing free-text answers that complicate automated screening.

Consent Language

Explicit consent to share data with partners and to receive electronic notices ensures informed participation and supports legal compliance.

Attachment Area

Designated upload fields specifying acceptable file types and size limits reduce intake friction and avoid incomplete submissions.

Signature and Date

A signature block that accepts handwritten or electronic signatures plus an explicit date is essential for establishing intent and start of obligations.

Audit Metadata

Capture signer IP, timestamp, and action log so every submission has a retrievable audit trail for review and dispute resolution.

Data and Security Fields to Protect

PII: Name, DOB
Contact: Address, phone
Financial: Income, banking
Health: Medical details
Consent: Data-sharing choices
Audit: Timestamps, IP

Common Preparation Pitfalls to Avoid

  • Submitting blurry or truncated document scans that prevent identity verification and cause intake delays.
  • Entering inconsistent name formats between the form and official ID, triggering additional proof-of-identity requests.
  • Omitting required attachments or failing to label files clearly, which can pause application processing.
  • Using informal date formats or nonstandard abbreviations that interfere with automated validation rules and deadlines.

Risks of Incomplete or Incorrect Enrollment Forms

Benefit Delay: Processing interruptions
Denial: Failure to meet criteria
Fiscal Penalty: Reporting fines possible
Data Breach: Unauthorized disclosure risk
Audit Finding: Noncompliance citation
Reputational: Loss of trust

Configuring an Online Enrollment Workflow

Typical settings help ensure secure, auditable, and user-friendly online completion and routing of the enrollment form.

Field Configuration
Authentication Method Email link or SMS code for signer verification
Automatic Detection Use magic fields to prefill known data securely
Conditional Logic Show or hide fields based on prior answers
Notifications Webhook or email alerts to intake team

Technical Requirements for Digital Submission

Ensure the chosen platform supports required security standards, audit trails, and any vendor integrations needed by administrators.

  • File Types: PDF, DOCX, JPG supported
  • Integrations: CRM and cloud storage compatible
  • Authentication: Email, SMS, and SSO options

Timelines and Typical Processing Expectations

Understand common timelines for submission, initial review, and final determination so applicants and staff can plan follow-up tasks.

Enrollment Window:

Varies by program; confirm published open and close dates

Initial Review:

Typically 3–10 business days after complete submission

Verification Follow-Up:

Request responses usually within 7–14 days

Final Decision:

Often issued within 14–30 days of receipt

Appeals Period:

Check program policy for formal appeal deadlines

eSignature Vendor Pricing Snapshot for Enrollment Forms

This vendor comparison highlights common pricing and compliance features relevant to digitizing enrollment forms; signNow appears first by design.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes, 7-day trial No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Real Examples of Enrollment Workflows in Practice

The following condensed examples show how organizations use electronic enrollment to streamline intake and documentation.

Optica Ventures (COO)

They replaced paper intake with an online form to reduce processing time and errors.

  • The project focused on identity matching and uploads.
  • As a result, the team reported easier customer interactions and faster onboarding while keeping secure records for audit and reporting purposes.

Tech Data (CEO)

Tech Data standardized enrollment across multiple sites to centralize approvals and reporting.

  • Bulk send and templating were key.
  • Standardized templates and automated routing reduced administrative rework and improved timeliness of benefit disbursal to approved applicants.

Practical Tips for Accurate and Efficient Enrollment

Small process changes can significantly reduce errors and speed up determinations.

Use Clear Field Labels
Label fields with examples and required formats to reduce entry mistakes and the need for follow-up.
Require Attachments Upfront
Collect all necessary documentation at submission to avoid iterated requests and processing delays.
Validate Before Submit
Implement client-side checks and explain common errors to applicants before final submission.
Preserve Audit Trails
Capture timestamps, IPs, and signer attribution for every signed form to support compliance and dispute resolution.

Frequently Asked Questions About Enrollment Forms

Answers to common questions about signing, submission, and legal validity for the UCB Cares Program Enrollment Form.


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