To: UCR Employee From: Theron Lyon, Benefits Manager Re: Short Term Disability (University Paid Temporary Disability-UTD) Supplemental Disability (Employee Paid Temporary Disability-ETD) We have been notified that you may be filing a claim under one or both of the disability plans listed above. In order to establish a disability claim, you must complete the Liberty Mutual Disability Claim Form and your physician must complete the Liberty Mutual Attending Physician’s Statement and return it to Liberty Mutual, Disability Claims, P.O. Box 37500, Phoenix, AZ 85069-7500. If you will be on an approved leave of absence without pay, you are eligible to continue your benefits during this period. Please read the “Disability Factsheet” for complete benefit details. To continue your benefits, you will need to complete a Benefits Insurance Continuation Form (BIC) available through the Benefits or Payroll Office. You may also qualify for the Family Medical Leave (FML), please contact your Department Personnel Assistant (DPA) for more information. Also, contact Parking Services at extension 24395 regarding your payroll deduction. Benefits received under UTD are taxable and must be reported when you file your federal income tax return. Liberty Mutual will issue a W-2 form covering the amount of taxable income received from your disability pay. In general, the law permits exclusion of a limited amount of these benefits payments from taxable income only if the employee is permanently and totally disabled, as defined by IRS regulations. Please keep a record of UTD payments you receive for use when preparing your tax return. This information is intended to serve only as a general guideline. Consult a tax professional for more information. Retirement plan members who are coordinated with Social Security will have FICA withheld from their UTD benefits at the current rate. If you have been employed by the University for less than 18 months, you may qualify for State Disability Insurance. Please contact the State Disability Office at (800) 480-3287 for more details. It is your responsibility to keep your department regularly informed of your status during your disability. If you have any questions or concerns, please contact Tina Rodriguez at (951) 827-1440.