University of Wisconsin-Madison

Insurance Prepayment/Reinstatement Request

This request is:
  Person ID
Employee Name (Last, Frst, Middle Initial
Date employee will be off payroll (mm/dd/yyyy)
 Date employee will be back on payroll (mm/dd/yyyy)
Reason for Submitting:
Family Medical Leave (FMLA)
Worker's Compensation LOA
Seasonal LOA
Other LOA
Reinstatement		 Missed
      Classified A Payroll
      Classified B Payroll
      Unclassified Reg Payroll
      May Multiples
Insufficient Earnings
Paid on End of Month Payroll
Recommend Payments to be made by:
Personal Payment Payroll Deduction
Comments:
Date (mm/dd/yyyy)
 Requestor
 Email Address
Campus Phone


 

UW1540 09/07

File last updated:September 12, 2007
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UW1540 06/07