University of Wisconsin Service Center

Health Insurance Rate Addition to Quick File

Instructions

Requestor's Name
Email Address
Telephone
Carrier Name
Deduction Code
County Name
County Code
Employee Contribution
Regular
Adjustment
State Contribution
Regular
Adjustment
Coverage
Regular
Grad		 Family
Single
Payroll Months to be Adjusted

Jan

Feb

Mar

Apr

 May

Jun
Jul Aug Sep
Oct Nov Dec
Employee's Name

Person ID

Comments:



File last updated: March 19, 2007
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