Forms & Publications

Employee Benefits

 

State Group Health Insurance

Dental Wisconsin

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 (2014) - Complete and submit to your institution’s benefits office to enroll in the plan.
  • Application (2015) - (for coverage beginning 1/1/15 and later) 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)

Tax-Sheltered Annuity 403(b) Program

Wisconsin Deferred Compensation 457 Program

Domestic Partnership Benefits

Family Medical Leave (Wisconsin & Federal)

Leave Benefits