Benefit and Payroll Forms
This forms area is a quick method for printing or ordering forms.
New Employee Packets can be ordered from the Materials Distribution Center (MDS).
Benefits | Insurance | General | Payroll
| BENEFITS | ||
|---|---|---|
| Accidental Death & Dismemberment Insurance | Application UW1245 | |
| Application - Continuation UW1249 | ||
| Application - Pilot HRIS B1247 | ||
| Application - History HRIS B1248 | ||
| Certificate | ||
| Fact Sheet UWS B1246 | ||
| Dental Insurance | Application OSER/UW Application | |
| Application - Continuation UWS-61 | ||
| Plan Summary | ||
| HMO Handbook DC DC-83445-7, -9999 | ||
| HMO Provider Directory | ||
| PPO Handbook DB DC-83445-8, -18 | ||
| PPO Provider Directory | ||
| Supplemental Handbook DC DC-83445-9, -19 | ||
| Domestic Partner Affidavit/Termination | Domestic Partnership -- Affidavit - UWS50 | |
| Domestic Partnership--Termination - UWS51 | ||
| Employee Reimbursement Accounts Program | Application | |
| Automastic Premium Conversion Waiver/Revocation of Waiver | ||
| Booklet | ||
| Change Form | ||
| Employment Eligibility Verification | I-9 Employment Eligibility Verification | Online |
| UW-Madison I-9 Reference Manual | Online | |
| Group Health Insurance | Application/Change Form ET-2301 | |
| Application for Continuation for 2009 ET-2311 | ||
| Application for Continuation for 2010 ET-2311 | Online | |
| Affidavit for Insurance Purposes UWS 93 | Online | |
| Booklet "It’s Your Choice" for Classified and Unclassified ET-2107 | ||
| Booklet "It’s Your Choice" for Graduate Assistants ET-2127 | ||
| Eligibility for Standard Plan Tier 2 Premiums UW1106 | ||
| State Group Life Insurance |
Application - Continuation ET-2154 | |
| Application - Conversion ET-2306 | ||
| Application - Enrollment/Change ET-2304 | ||
| Application - Evidence of Insurability ET-2305 | ||
| Beneficiary Designation Form ET-2320 | ||
| Booklet ET-2101 | ||
| Premium Waiver Request ET-5306 | ||
| Income Continuation Insurance | Application ET-2307 | |
| Application - Evidence of Insurability ET-2308 | ||
| Brochure ET-2106 | ||
| Individual and Family Group Life Insurance | Application 03-30539 | |
| Application - Conversion 03-30573 | ||
| Application - Evidence of Insurability 03-30538 | ||
| Beneficiary Designation Form F53232 | ||
| Brochure F. 59114 | ||
| Conversion Brochure F4638-11 | ||
| Certificate 03-30541 | ||
| Transfer of Ownership F66318-2 | ||
| Dental & Excess Medical (EPIC) a/k/a Major Medical | Application E11444 | |
| Application - Continuation E11472-0903 | ||
| Affidavit for Insurance Purposes UWS 93 | ||
| Beneficiary Designation Form | ||
| Brochure E11549 | ||
| Tax Sheltered Annuities | Question and Answer Guide UWS32 | |
| Salary Reduction Agreement UWS31 | ||
| University Insurance Association, Life Insurance | Continuation Application UWS1206 | |
| Application - Conversion | ||
| Beneficiary Designation Form F. 59786 | ||
| Certificate 03-30564 | ||
| Living Benefit F.40567 | ||
| Transfer of Ownership F66318-2 | ||
| UW Employees Inc. Life Insurance | Application GA-1314 | |
| Application - Evidence of Insurability GA-1129 | ||
| Beneficiary Designation Form GA-562 | ||
| Brochure GA-1117 | ||
| Certificate UW/GIC/05 | ||
| Vision Insurance | Application - Continuation | |
| OptumHealth Vision Summary | ||
| Worker's Compensation | Employer's First Report of Injury or Illness WKC-12 | |
| Supervisor's Accident Analysis and Prevention Report WKC-SUP | ||
| Worker's Compensation Timesheet UW1059 | ||
| General | Domestic Partnership - Affidavit UWS50 | |
| Domestic Partnership - Termination Affidavit UWS51 | ||
| Notice of Benefit Eligibility UW1030 | ||
| Rehired Annuitant Election ET-2319 | ||
| INSURANCE | ||
| Insurance | Insurance Prepayment/Reinstatement Request UW1540 | |
| GENERAL | ||
| Employee Benefits | Rehired Annuitant Report ET-2319 | |
| PAYROLL FORMS | ||
| Employee Information | Direct Deposit Authorization UW1032 | |
| Employee Information UW1035 (fillable) | ||
| Home Address Report UW1264 | ||
| Senority Information UW1058 | ||
| Payroll | Checksheet (Blank) UW1011 | |
| Check Stop Payment UW1368 | ||
| Missed Punches (Kronos) UW1537 | ||
| Paycheck Correction UW1383 | ||
| Report Request UW1263 | ||
| Salary Advance Request UW1275 | ||
| Special Award Payment UW1276 | ||
| Missed Payroll Request UW1274 | ||
| Temporary Payroll Number Request UW1051 | ||
| Taxes | W-4 Form Employee’s Withholding Allowance Certificate UW1389 | |
| International Tax Packet UW1469 | ||