Date Reported: - UCLA College



Death Notice

UCLA Office of the Chancellor

Name of the Deceased Title

Date of Death Time of Death (if known)

Date of Employment Started at UC Date Retired

Name of Surviving Spouse, Next of Kin, or Close Personal Friend

Address of Surviving Spouse, Next of Kin, or Close Personal Friend

Dependent (if other than Surviving Spouse or Next of Kin)

Address (if other than above)

Informant – Department Contact & Extension Today’s Date

The University Flag (located at Pauley Pavilion) will be at half-mast on

The home department shall report the death of the deceased faculty member by completing and submitting this form immediately to the Chancellor’s office. It is recommended to also notify the Chancellor’s Office by phone (ext. 52121) and CHR’s Benefits and Personnel Services (ext. 40830) upon submission of this form. The Chancellor’s Office will notify the Payroll Office of the faculty member’s death to begin the death payment process. For further instructions, see as well as the information on Page 2.

Note – The following offices will receive copies of this notice:

1. Chancellor’s Communications Service, 3148 Murphy Hall, 140501

2. Media Relations, James West Center, 143107

3. Payroll, 10920 Wilshire Blvd., 6th Floor, 141648

4. Academic Senate (faculty), 3125 Murphy Hall, 140801

5. Campus Benefits, Suite 200, 10920 Wilshire Blvd., 146548

6. Emeriti Center, 1116 Rolfe Hall, 143702

7. UC President’s Office (fax 510/987-9086; Voice Mail 510/987-9082)

8. UCLA Healthcare Human Resources Office, UCLA Wilshire Center, Suite 400, 167648

Overview of Tasks when Reporting the Death of a Faculty Member:

The Department Responsibility,

- Contact the Chancellor's Office at ext. 52121 to report the active employee death and submit this form. The Chancellor's Office sends out a notice to UCOP, the Campus Payroll Office and CHR.

- Report the date of death if known, but not the cause of death as the cause of death is not legally something we're entitled to know.

- Contact the CHR Benefits Office to report the death,

- End the decedents' appointment in EDB using the separation bundle.

CHR Benefits Office Responsibility,

- Look up the beneficiary on record and to write to them asking for a certified copy of the death certificate.  If no beneficiary has been designated the Benefits Office may call the decedent's department and ask for the name and contact information of a family member.

- Once the copy of death certificate is received the Benefits Office coordinates a claim to be mailed to the Prudential Life Insurance Company for processing and payment to the beneficiary.

- If an "assignment" has been coordinated to pay for funeral services to the funeral home then the Benefits Office will coordinate this directly with the funeral home.  Usually the beneficiary or family member interacts between the funeral home and the Benefits Office to transmit the assignment form.

- If the employee had AD&D coverage then the Benefits Office will also file a claim with the AD&D underwriter, which may require another copy of the death certificate.

- The Benefits Office notifies the UCOP Special Claims Unit of the employee death.

- The Benefits Office shares beneficiary information with the campus Payroll Office.

UCOP Special Claims Unit Responsibility,

- Coordinate any CAP payment to the beneficiary,

- Coordinate any applicable UCRP survivor benefits,

- Coordinate the UCRP Basic Death Benefit in the amount of $7,500

Campus Payroll Office Responsibility,

- Coordinate outstanding vacation time, comp time and final paycheck to beneficiary.

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