Forms & Publications
ShareEmployee Benefits
State Group Health Insurance
- Application - Complete and submit to your institution’s benefits office to enroll in the plan.
- Affidavit for Insurance Purposes – Dependent Lacks Social Security Number due to Non-Citizenship - Complete and submit with your health insurance application if your covered family member is not a United States citizen and does not have a Social Security number.
Dental Wisconsin
- Application - Complete and submit to your institution’s benefits office to enroll in the plan.
EPIC+ Benefits
- Application - Complete and submit to your institution’s benefits office to enroll in the plan.
- Beneficiary Designation - Complete and submit to EPIC Life Insurance Company to name who you would like to receive benefits payable upon your death under the Accidental Death and Dismemberment provision.
- Hospital/Surgery Claim Form & Instructions - Complete and submit to EPIC Life Insurance Company to file a claim for an outpatient surgery or hospital confinement.
- Life and AD&D Claim Form - Complete and submit to EPIC Life Insurance Company to file a claim for a death or dismemberment.
- Davis Vision Claim Form - Complete and submit to Davis Vision to file a claim for vision services received out of the Davis Vision network.
VSP Vision Insurance
- Application (for coverage effective 1/1/2014) - Complete and submit to your institution’s benefits office to enroll in the plan.
- Application (for 2013 enrollments) - Complete and submit to your institution's benefits office to enroll in the plan.
Employee Reimbursement Account (ERA)
- Application - Complete and submit to your institution’s benefits office to enroll in the plan.
- Change in Status Form - Complete and submit to WageWorks within 30 days of a change in status if you want to enroll, increase, decrease or cancel your coverage.
- Health Care FSA Claim Form - Complete and submit form to WageWorks to request a reimbursement for eligible medical expenses for you or your eligible dependents.
- Dependent Day Care FSA Claim Form - Complete and submit form to WageWorks to request a reimbursement for eligible dependent care expenses for your eligible dependents.
- Automatic Premium Conversion Waiver/Revocation of Waiver Form - Complete and submit form to your institution’s payroll office if you do not want benefit premiums taken on a pre-tax basis. If you waived participation in Automatic Premium Conversion, you may also use this form to elect to start having your premiums deducted on a pre-tax basis again.
- Health Care FSA Continuation Form - Contact your benefits office if you need a continuation form.
State Group Life Insurance
- Application - Complete and submit to your institution’s benefits office to enroll in the plan.
- Beneficiary Designation - Complete and submit to Department of Employee Trust Funds (ETF) to name who you would like to receive benefits payable upon your death.
- Living Benefit Brochure - If you are terminally ill with a life expectancy of 12 months or less, read the Living Benefits brochure to determine if you’d like to apply for living benefits.
- Conversion Form - Complete and submit to Minnesota Life if you want to convert your coverage to an individual policy at end of employment. Your benefits office must complete the Employer Section before it is submitted to Minnesota Life.
- Medical Evidence of Insurability Form - Complete and submit to Minnesota Life if you want to apply for coverage through Evidence of Insurability. Your benefits office must complete the Employer Section before it is submitted to Minnesota Life.
- Continuation Form - Contact your benefits office if you need a continuation form. Continuation at retirement is automatic.
Individual and Family Group Life Insurance
- Application - Complete and submit to your institution’s benefits office to enroll in the plan.
- Beneficiary Designation - Complete and submit to UW System Administration to name who you would like to receive benefits payable upon your death.
- Accelerated Death Benefit Form - Complete and submit to Minnesota Life if you have a terminal illness with a life expectancy of less than 12 months and want to apply for benefits payable during your lifetime. Your benefits office must complete the Employer Section before it is submitted to Minnesota Life.
- Conversion Form - Complete and submit to Minnesota Life if you want to convert your coverage to an individual policy at end of employment. Your benefits office must complete the Employer Section before it is submitted to Minnesota Life.
- Medical Evidence of Insurability Form - Complete and submit to Minnesota Life if you want to apply for coverage through Evidence of Insurability. Your benefits office must complete the Employer Section before it is submitted to Minnesota Life.
UW Employee's Inc. Life Insurance
- Application - Complete and submit to your institution’s benefits office to enroll in the plan.
- Beneficiary Designation - Complete and submit to Minnesota Life to name who you would like to receive benefits payable upon your death.
- Paper Beneficiary Designation
- Online Beneficiary Designation (will receive login information from Minnesota Life after your application is processed)
- Accelerated Death Benefit Form - Complete and submit to Minnesota Life if you have a terminal illness with a life expectancy of less than 12 months and want to apply for benefits payable during your lifetime. Your benefits office must complete the Employer Section before it is submitted to Minnesota Life.
- Conversion Application - Complete and submit to Minnesota Life if you want to convert your coverage to an individual policy at end of employment. Your benefits office must complete the Employer Section before it is submitted to Minnesota Life.
- Medical Evidence of Insurability Form - Complete and submit to Minnesota Life if you want to apply for coverage through Evidence of Insurability. Your benefits office must complete the Employer Section before it is submitted to Minnesota Life.
University Insurance Association Life Insurance
- Beneficiary Designation - Complete and submit to Minnesota Life to name who you would like to receive benefits payable upon your death.
- Accelerated Benefit Form - Complete and submit to Minnesota Life if you have a terminal illness with a life expectancy of less than 12 months and want to apply for benefits payable during your lifetime.
- Conversion Form - Complete and submit to Minnesota Life if you want to convert your coverage. Your benefits office must complete the Employer Section before it is submitted to Minnesota Life.
- Continuation Form - Contact your benefits office if you need a continuation form.
Accidental Death and Dismemberment
- Application - Complete and submit to your institution’s benefits office to enroll in the plan.
- Beneficiary Designation - Complete and submit to UW System Administration to name who you would like to receive benefits payable upon your death.
- Conversion Bulletin - Follow the instructions on the conversion bulletin to learn how to convert your group policy to an individual policy. Must be under age 70 to convert.
- Continuation Form - Contact your benefits office if you need a continuation form.
Income Continuation Insurance
- Application - Complete and submit to your institution’s benefits office to enroll in the plan.
- Medical Evidence of Insurability - Complete and submit to ETF if you want to apply for coverage or decrease your waiting period through Evidence of Insurability. Your benefits office must complete the Employer Section before it is submitted to ETF.
- Sick Leave Usage During Disability Claim (UWS-430) - Complete this form only if you are applying for a WRS Disability annuity (40.63), a Long-Term Disability Insurance (LTDI) benefit or a Duty Disability benefit at the same time you are applying for an ICI benefit.
Wisconsin Retirement System (WRS)
- Beneficiary Designation
- Beneficiary Designation (alternate)
- Benefit Information Request
- Election to Participate in Variable Fund
- Canceling Variable Participation
- Retirement Estimate Request
- Maximum Additional Contribution Worksheet
- Additional Contributions Brochure
- Applying for Your Retirement Benefit Brochure
- Buying Other Governmental Service Brochure
- Buying Creditable Services Brochure
- Calculating Your Retirement Benefits Brochure
- Choosing an Annuity Options Brochure
- Death Benefits Brochure
- Disability Benefits Brochure
- How Divorce Can Affect Your WRS Benefits Brochure
- How Participation in the Variable Trust Affects Your WRS Benefits Brochure
- How to Retire Brochure
- Military Service Credit Brochure
- s. 40.65 Duty Disability and Survivor Benefits Brochure
- Separation Benefits Brochure
- Your Benefit Handbook Brochure
Tax-Sheltered Annuity 403(b) Program
Wisconsin Deferred Compensation 457 Program
- Enrollment Form - Simplified
- Enrollment Form - Complete
- Catch-up Contribution Application
- Beneficiary Designation
- Incoming Transfer/Direct Rollover
- Personal Information Change Request
- WDC Forms and Brochures Page
- Program Highlights
- Fact Sheet
- Investment Planning Guide
- Catch-up Contributions Brochure
- Understanding Your Distribution Options Brochure
- Retirement Guide
- Money Talks Newsletter
- Plan Document
Domestic Partnership Benefits
- ETF Affidavit of Domestic Partnership (ET-2371) - Use to create a Chapter 40 domestic partnership
- ETF Affidavit of Termination of Domestic Partnership (ET-2372) - Use to end a Chapter 40 domestic partnership
- UW System Affidavit of Domestic Partnership (UWS-50) - Use to create a UW System domestic partnership (do not use if Chapter 40 domestic partnership already established)
- UW System Affidavit of Termination of Domestic Partnership (UWS-51) - Use to end a UW System domestic partnership (do not use if trying to end a Chapter 40 domestic partnership)
- Domestic Partner Brochure (ETF)
- Tax Dependent Status Worksheet
- Dependent Tax Status Change Form (UW1541)
Family Medical Leave (Wisconsin & Federal)
- Comparison of FMLA and WFMLA
- Employee Request for W/FMLA (UWS 80) - Complete and submit this form to your institution to request W/FMLA-protected leave. If you request a WFMLA leave to care for a domestic partner or a domestic partner's parent, you must complete this form in order to certify the domestic partnership for WFMLA purposes.
- Certification by Health Care Provider for Employee’s Serious Health Condition (UWS 82) - Your health care provider must complete this form to certify your serious health condition if you are taking a concurrent FMLA and WFMLA leave. Note: if you are taking a WFMLA leave only - you should use the WFMLA Certification form (UWS 82a) to certify your own serious health condition.
- WFMLA Certification form (UWS 82a) - If you are taking a WFMLA leave only - you should use this form to certify your own serious health condition.
- Certification by Health Care Provider for a Family Member’s Serious Health Condition (UWS 83) - Your family member's health care provider must complete this form to certify their serious health condition if you are taking a concurrent FMLA and WFMLA leave. Note: if you are taking a WFMLA leave only - you should use the WFMLA Certification form (UWS 83a) , to certify your family member's serious health condition.
- WFMLA Certification form (UWS 83a) - If you are taking a WFMLA leave only - you should use the this form to certify your family member's serious health condition.
- Certification of Qualifying Exigency for Military Family Leave (UWS 84) - Complete and submit this form to your institution to certify that an exigency was created because a family member is on covered active military duty or has been notified of an impending call or order to active duty to a foreign country or international waters. The family member may be in either the regular or reserve component of the Armed Forces.
- Certification of Serious Injury or Illness of a Current Servicemember or Veteran for Military Caregiver Leave (UWS 85) - Complete and submit this form to your institution to request FMLA-protected leave to care for a current military servicemember or veteran, who is a family member or next of kin, who is seriously ill or injured due to military service.