UW-Madison Payroll and Benefits Services

New Employees Page
Employee Forms

Direct Deposit | Submit to the Office of Human Resources, 21 N Park St. Suite 5101
Direct Deposit Authorization
W-4 Form Packet | Includes W-4 Employee's Withholding Allowance Certificate and Employee Self-Identification (Ethnicity and Heritage, Disability, and Veterans Survey)
I-9 Employment Eligibility Verification

Your hiring department will email you a link to the electronic I-9 system and login instructions. Section 1 of the electronic I-9 form must be completed on or before the first day of your appointment. The electronic I-9 system will provide the lists of acceptable documents and detailed instructions on how to complete the form. The required documents must be presented in person to your hiring department within three days of your appointment start date.
Employer/Administrator Forms

New Employee Checklist
- Employee Benefits Checklist for Classified & Unclassified Staff, UW1036
- Employee Benefits Checklist for Graduate Assistants, UW1045

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State Group Health Plan Page
Publications

It's Your Choice: 2012 Decision Guide

It's Your Choice: 2012 Reference Guide

It's Your Choice: 2011 Decision Guide

It's Your Choice: 2011 Reference Guide

Standard Plan

Decision Guide 2012 Corrections/Updates
Decision Guide 2011 Corrections/Updates
Employee Forms

Application | Submit to your Payroll & Benefits Office.
Affidavit for Non-citizen Insurance | Submit to your Payroll & Benefits Office
- Affidavit for Insurance Purposes, UWS 93
  Complete this form if you are unable to provide a Social Security Number for a non-citizen spouse or non-citizen eligible dependent. Submit the Affidavit with your application.
Authorization to Disclose Medical Information
Authorization to Disclose Medical Information, ET-7414
Health Insurance During Military Leave
Health Insurance Election For Military Service Personnel, ET-2350
Dependent Tax Status Change
Dependent Tax Status Change Form, UW1541
Complaint Form
Employee Trust Funds Complaint, ET-2405
Employer/Administrator Forms

Continuation Application
- Application for Continuation, ET-2311 (2012)
Tier 2 Eligibility
Eligibility for Standard Plan Tier 2 Premiums, UW1106
Domestic Partnership Processing Checklist
Domestic Partnership Processing Checklist

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EPIC Benefits+ Plan Page
Publications

2012 Benefits+ Brochure

2011 Benefits+ Brochure

EyeMed Discount Summary

Certificate of Coverage

Changes and FAQ

2012 Dental Plan Comparison Chart
2011 Dental Plan Comparison Chart

Employee Forms

Application | Submit to your Payroll & Benefits Office
Benefits+ Enrollment Form, E11444
Affidavit for Insurance Purposes | Submit to your Payroll & Benefits Office
Affidavit for Insurance Purposes, UWS 93
Complete this form if you are unable to provide a Social Security Number for a non-citizen spouse or non-citizen eligible dependent. Submit the Affidavit with your application.

Beneficiary Designation | Submit to EPIC
Beneficiary Designation Form
Employer/Administrator Forms

Continuation Form
EPIC Benefits+ Continuation Form, E11472

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Anthem Dental Insurance Plans Page
Publications

2012 DentalBlue Plans

2012 Frequently Asked Questions

HMO Handbook

PPO Handbook

Supplemental Handbook

HMO Provider Directory
PPO Provider Directory
2012 Dental Plan Comparison Chart
2011 Dental Plan Comparison Chart

Employee Forms

Application | Submit to your Payroll & Benefits Office
Anthem Group DentalBlue Application for OSER/UW
Employer/Administrator Forms

Continuation Application
DentalBlue Continuation Form, UWS-61

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Dental Wisconsin Plan Page
Publications

2012 Dental Wisconsin Brochure

2011 Dental Wisconsin Brochure

Frequently Asked Questions

2012 Dental Plan Comparison Chart
2011 Dental Plan Comparison Chart

Employee Forms

Application | Submit to your Payroll & Benefits Office
Dental Wisconsin Enrollment Form, UWS 64
Employer/Administrator Forms

Continuation Form
Dental Wisconsin Continuation Form, E13000

VSP Vision Insurance Plan Page
Publications

Plan Year 2012

Plan Year 2011

Certificate of Coverage

Employee Forms

Application | Submit to your Payroll & Benefits Office
Vision Plan Application, UWS66
Employer/Administrator Forms

Continuation Form
Election of Continued Vision Coverage, UWS-67

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Employee Reimbursement Accounts Program Page
Publications

Plan Year 2012 Booklet
Employee Forms

Application | Submit to your Payroll & Benefits Office
ERA Enrollment Form, FBMC/WIS
Change In Status | Submit to Fringe Benefits Management Company
- Change In Status Form
- Change in Status Information
Reimbursement | Submit to Fringe Benefits Management Company
- Rapid Refund Authorization Form
- Employee Reimbursement Account Claim Form, FBMC/WISC/1203
Premium Conversion Waiver
Automatic Premium Conversion Waiver/Revocation Of Waiver
Employer/Administrator Forms

Continuation Form
Medical Expense Account Continuation Election Form, ET-1518
Medical Expense Account after termination
If you terminate employment or cease to be an eligible employee prior to the end of the plan year and do not arrange to continue your coverage, your coverage ends at the end of the month in which your last ERA payroll deduction was taken. Expenses for services provided to you after this date are not reimbursable.

Dependent Care Account after termination
If you terminate employment or cease to be an eligible employee prior to the end of the plan year, you cannot continue dependent care contributions. You can continue to request reimbursement for eligible expenses from your Dependent Care Account until you exhaust your account balance or March 15, whichever comes first, even if you have not contributed the full annual amount for which you enrolled. Valid expenses are those that are incurred for the care of a qualified dependent so that you (and your spouse) can work, look for work, or attend school full-time.

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Income Continuation Insurance Plan Page

Publications

Income Continuation Insurance

Employee Forms

Application | Submit to your Payroll & Benefits Office

Income Continuation Insurance Application, ET-2307

Evidence of Insurability | Submit to ETF

Evidence of Insurability, ET-2308

If you do not enroll for ICI coverage when you are first eligible, you can enroll only by completing an Evidence of Insurability application.

Sick Leave Usage | Submit to the Office of Human Resources, 21 N. Park St., Suite 5101

Sick Leave Usage Election at Time of Claim, UW1456

Complete this form only if you are applying for a WRS Disability annuity, an LTDI benefit, or a § 40.65 Duty Disability benefit from the Department of Employee Trust Funds at the same time that you are applying for Income Continuation Insurance benefits.

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State Group Life Plan Page
Publications

Plan Booklet

Group Life Insurance After You Terminate Employment
Employee Forms

Application | Submit to your Payroll & Benefits Office
- Life Insurance Application / Cancellation / Refusal, ET-2304
- How to Enroll a Domestic Partner and his/her Eligible Dependent
Evidence of Insurability | Submit to Minnesota Life Insurance
Evidence of Insurability, ET-2305
If you do not enroll during your initial enrollment period, you may apply for coverage using this form.

Beneficiary Designation | Submit to ETF
Beneficiary Designation, ET-2320
Conversion | Submit to Minnesota Life Insurance
Conversion of Group Life Insurance Enrollment, ET-2306
Employer/Administrator Forms

Continuation Application
Wisconsin Public Employers’ Group Life Insurance Program Continuation Application, ET-2154
Premium Waiver Request
Request for Disability Premium Waiver, ET-5306

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Individual and Family Group Life Plan Page
Publications

Individual and Family Group Term Life Insurance

Fact Sheet

Certificate of Insurance

Employee Forms

Application | Submit to your Payroll & Benefits Office
Application / Cancellation / Change Request, UWS 1301
Evidence of Insurability | Submit to Minnesota Life Insurance
Evidence of Insurability, 03-30538
If you do not enroll for coverage when you are first eligible or would like to increase your coverage beyond the annual increase option amount, you can apply by completing an Evidence of Insurability application.

Conversion Application | Submit to Minnesota Life Insurance
Conversion of Group Life Insurance Enrollment, 03-30573
Beneficiary Designation | Submit to UW System Administration
Beneficiary Designation, UWS 1305
Transfer of Ownership | Submit to Minnesota Life Insurance
Transfer of Ownership, F66318-2

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Employer/Administrator Forms

Request for Disability Premium Waiver
Request to Initiate Disability Premium Waiver Claim, UWS-B1225

University Insurance Association Life Plan Page
Publications

Fact Sheet

Certificate of Insurance

Employee Forms

Conversion | Submit to Minnesota Life Insurance
Conversion of Group Life Insurance Enrollment, EdF68525
Beneficiary Designation | Submit to Minnesota Life Insurance
Beneficiary Designation, F59786
Living Benefit | Submit to Minnesota Life Insurance
Notice of Claim for Living Benefit, F45067
Transfer of Ownership | Submit to Minnesota Life Insurance
Transfer of Ownership, F66318-2
Employer/Administrator Forms

Continuation Application
Continuation Application/Ballot Request, UWS 1206

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UW Employees, Inc. Life Plan Page

Publications

Brochure

Certificate of Insurance

Employee Forms

Application | Submit to your Payroll & Benefits Office

Application for Enrollment or Cancellation

Coverage is effective on the first of the month after your Payroll & Benefits Office has received your application.

Evidence of Insurability | Submit to Minnesota Life Insurance

Evidence of Insurability

If you do not enroll during your initial enrollment period, you may apply for coverage using this form.

Employee Forms

Affidavit of Employment with a WRS Participating Employer Prior to July 1, 2011

Affidavit of Employment with a Wisconsin Retirement System (WRS) Participating Employer Prior to July 1, 2011

Long-Term Disability Claim

Claim Filing Instructions for the Income Continuation Insurance (ICI) and Long-Term Disability Insurance (LTDI) Plans, ET-5106

Sick Leave Election

Sick Leave Election, UW1456

Additional Contribution Election

Beneficiary Designation

Beneficiary Designation, ET-2320

Benefit Information Request/Estimate

Benefit Information Request, ET-7301

Qualified Domestic Relations Order

Order to Divide Wisconsin Retirement System Benefits, ET-4926

Income Tax Withholding for Retirees

Income Tax Withholding Election, ET-4310

Rehired Annuitant Election

Rehired Annuitant Election, ET-2319

Election to Cancel Variable Participation

Canceling Variable Participation, ET-2313

Election to Participate in the Variable Trust Fund

Election to Participate in the Variable Trust Fund, ET-2356

Your Variable Trust Fund participation will become effective on the January 1 after the date your election is received. If you are a new WRS participant and ETF receives your Variable Trust Fund election form within 30 days after the date your WRS-covered employment begins, your election becomes effective immediately on the date your employment began.