Name / Address Change Form | Human Resources

This form is used for Name and Address changes

Current Name*
First Middle Last
Employee Number (6 Digit Number)*
Employee Email (Address MUST include @uchc.edu)*
What do you want to change/update? Check all that apply:*
- Address
- Name
- Marital Status
- Dependent/Beneficiary
- Emergency Contact
ADDRESS CHANGE
Previous Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
New Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Personal Email
NAME CHANGE
Special Note: An updated Social Security card with your new name is required to initiate a name change. Please email your updated social security card to hr-operations@uchc.edu
New Name
First Middle Last
MARITAL STATUS CHANGE
Change Reason
Explanation of Other
Effective Date
MM slash DD slash YYYY
DEPENDENT / BENEFICIARY CHANGE
Please Note: Adding/removing dependents to health insurance coverage must be done within 30 days of a family status change (i.e., birth, adoption, marriage, divorce).
Appropriate forms will be forwarded to you if you check any question below
- Add/Cancel dependent coverage - Proof of change (legal document) must be provided to Human Resources
- Change retirement beneficiaries
- Change life insurance beneficiaries
EMERGENCY CONTACT CHANGE
Name
First Last
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone
AUTHORIZATION
authorization
I authorize UConn Health to make the appropriate changes to my employee data as noted on this form.
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

ADDRESS CHANGE

NAME CHANGE

MARITAL STATUS CHANGE

DEPENDENT / BENEFICIARY CHANGE

EMERGENCY CONTACT CHANGE

AUTHORIZATION