SSC - HR - Leave of Absence Upload eForm

Use this eForm to attach your completed and signed Benefit Election Form while on a Leave of Absence. 

Payments must be up to date and received by the payroll office to process your request. If electing to continue with benefits during the leave, please mail a check or money order to:

Payroll Office, University of Michigan, Wolverine Tower – Low Rise G395
3003 South State Street
Ann Arbor, MI 48109-1279
Please include your UMID on the memo line. 

This form does require processing and your submission will not immediately be available in Employee Self Service. Your username (uniqname) and Full Name will be recorded with this eForm submission.

For more information on benefits during a Leave of Absence, please visit the Benefits Website.

Attestation & Authorization

By authorizing below, you are acknowledging that the information provided on the form is correct to the best of your knowledge and that you are responsible for your benefits choice payment(s) based on the current rate and any future rate changes (increases or decreases).

Please use this as my authorization to process the requested changes
Please use this as my authorization to process the requested changes

Attach the Election to Continue Benefits while on a Leave form here:

File attachments associated with the ticket.
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Questions?


Call the Shared Services Center - HR Customer Care at 734-615-2000 locally, or toll free at 866-647-7657, if you have any questions or need additional assistance.  Click on the following link for assistance using the eForm: https://ssc.umich.edu/contact/

Shared Services Center - HR Customer Care is open Monday through Friday.  Click on the following link for the available customer service hours: https://ssc.umich.edu/human-resources/

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