University of Wisconsin Processing Center

Sick Leave Usage Election

Income Continuation Insurance/Disability

Complete this form 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 to elect the manner in which you chose to use your sick leave credits.

Employee Name (Last, First Middle)


Social Security Number

I have applied for benefits from the Income Continuation Insurance Program and have also applied for a WRS Disability annuity, an LTDI benefit, or a § 40.65 Duty Disability benefit from the Department of Employee Trust Funds. I understand that if the disability benefit is approved I may be eligible to use my accumulated sick leave credits to pay for my health insurance premiums.

I elect not to use any of my sick leave as paid time and understand I will not receive ICI benefits until the end of my waiting period (30 calendar days for the classified ICI plan or my selected waiting period for the unclassified ICI plan). I may use any other leave available, i.e. vacation, to continue receiving salary until the end of my waiting period. During any period when I am receiving no salary, I will need to prepay my insurance premiums until the WRS Disability, Duty Disability or LTDI benefit is approved. Once the benefit is approved, my accumulated sick leave will be used to pay my health insurance premiums.
I elect to use my sick leave as paid time in accordance with the following instructions (check one):
Use sick leave through the date of _____________________. If my WRS Disability, Duty Disability or LTDI benefit is not approved at that time, I will need to make arrangements to prepay my insurance premiums unless and until the premiums are waived. Once my WRS Disability, Duty Disability or LTDI benefit is approved, the remaining balance of my sick leave can then be converted to pay my health insurance premiums.
Use sick leave until exhausted. My ICI benefits will begin after my waiting period or at the time my sick leave is exhausted, whichever is later. If the WRS Disability, Duty Disability or LTDI benefit is not approved when my sick leave is exhausted, I will prepay my insurance premiums until the benefit is approved.
I understand that if I elected not to use all of my sick leave as paid time and the WRS Disability, Duty Disability, or LTDI benefit is not approved, I will be required by § 40.62 of the WI Statutes to use my sick leave up to the maximum 130 days. Future ICI benefits will be suspended until the accumulated amount of sick leave is used.
Date (mm/dd/yyyy)

Employee Signature Home Telephone Number

UW1456 01/01