Name/Address Change Form

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
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.

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Name/Address Change Form

See topics forHuman Resources

ADDRESS CHANGE

NAME CHANGE

MARITAL STATUS CHANGE

DEPENDENT / BENEFICIARY CHANGE

EMERGENCY CONTACT CHANGE

AUTHORIZATION

Current Name

Address Change

Previous Address

New Address

NAME CHANGE

New Name

MARITAL STATUS CHANGE

DEPENDENT / BENEFICIARY CHANGE

EMERGENCY CONTACT CHANGE

Name

Address