Benefits Administration
Employer Forms
- - Upon receipt and review of an employee's request for Catastrophic Leave, the employer shall complete this form to indicate approval/denial and forward to the Payroll Office for processing.
Continuation and conversion forms can be accessed below for reference. Employees should contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain continuation and conversion forms.
- - This form must be provided to an employee within 5 business days of an employee’s request for a WFMLA and/or FMLA-protected leave; or within 5 business days of learning an employee is eligible for coverage by WFMLA and/or FMLA.
- - This form must be provided to the employee who has requested a WFMLA and/or FMLA-protected leave to let the employee know if the leave is approved and/or if the employee needs to submit any additional information before the leave can be approved.
- - Complete this form if you (the employer) needs to obtain medical information directly from the health care provider.
ETF requires online submission of Sick Leave Conversion Credits through the online Accumulated Sick Leave System on the ETF’s On-line Network for Employers (ONE) system under “my ETF Benefits”. The online sick leave certification process provided through ETF’s system must be used for all employees. To request access review .
Additional Information and Tools
Resources
- State Group Health Insurance Manual - Chapter 12 - Accumulated Sick Leave Conversion Credits (ASLCC)
- UW System Administrative Policy 1212 (formerly BN 3): Sick Leave
- Sick Leave Credit Conversion Program Estimator
Training
- Sick Leave Credit Conversion Program Training - Webinar series available for viewing anytime. Registration required. Published by ETF.
- Module 1 - Provides an overview of the sick leave program, eligibility requirements and sick leave conversion credit calculations.
- Module 2 - Discusses employer and employee responsibilities, and when employers are to certify sick leave for their employees.
- Module 3 - Explains rehired annuitants, sick leave escrow, the sick leave re-enrollment process and what happens to a member’s sick leave in the event of death.
- Module 4 - Resources to assist employers helping employees considering terminating employment and the Q & A from the Sick Leave Credit Conversion Program in-person employer training.
An employee should initiate submitting an appeal for their FSA and/or HSA electronically by following the steps provided in the Appeals Guide. The deadlines for Annual Benefits Enrollment appeals are as follows:
- Flexible Spending Accounts (health care and dependent day care): January 31, 2021
- Health Savings Accounts: April 15, 2021
To schedule an Edvest workshop on your campus, contact Jessica Fandrich at Jessica.Fandrich@dfi.wisconsin.gov.
Employee Forms
Forms
Resources
- Comparison of Health & Pharmacy Benefits
- Glossary of Health Coverage and Medical Terms
- Guide to Office Visit Copays
- Health Plan Search
- How to Get Care When You Need It eLearning (ETF)
- It’s Your Choice Decision Guide
- Patient Rights and Responsibilities
- Plan Design Options eLearning (ETF)
- Preventive Health Services
- State & Federal Notifications
- Summary of Benefits & Coverage
- Terms and Conditions
- Affordable Care Act (ACA)
- Health Insurance Marketplace Notice
Certificate of Coverage
- 2021 Health Plan and High Deductible Health Plan (HDHP)
- 2021 Access Health Plan
- 2021 Access HDHP
- 2021 Pharmacy Benefits
Plan Administrators
- State Group Health Insurance: Department of Employee Trust Funds | 1-877-533-5020
- Pharmacy Benefits: Navitus Health Solutions | 1-866-333-2757
- Uniform Dental Benefits: Delta Dental of Wisconsin | 1-844-337-8383
last updated: 01/05/2021
- Certificate of Coverage - Uniform Dental
- Terms and Conditions
- Delta Dental | 1-844-337-8383 | Find a Provider | Video
- Terms and Conditions
- 2020: VSP | 1-800-877-7195
- 2021: DeltaVision/EyeMed | 1-855-544-6035 | Find a Provider | Video
- Conversion Form – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- Continuation Form – Contact your human resources office if you need a continuation form. (Continuation at retirement is automatic)
- Accelerated Death Benefit Form
- Conversion Form – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- LifeBenefits portal (can update beneficiary designation online)
- Conversion Form – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
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- Conversion Form – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- Conversion Form – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- Continuation Form – Contact UW-Shared Services, Service Operations at serviceoperations@uwss.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) if you need a continuation form.
- Terms and Conditions
- Securian | 1-866-295-8690
- Income Continuation Insurance Application (ET-2307)
- The Hartford | 1-800-960-0052
Flexible Spending Accounts (FSAs)
Health Savings Accounts (HSAs)
An HSA is only available to individuals enrolled in a High Deductible Health Plan (HDHP); it is a required component of the HDHP.
Parking and Transit Accounts
Plan Administrator
- 2020 FSA claims, HSA or Parking and Transit inquiries: Contact CYC at 833-881-8158 or service@connectyourcare.com or www.connectyourcare.com/ETF.
- 2019 HSA inquiries: If you did not transfer your HSA to CYC, the new administrator effective January 1, 2020, contact TASC at 844-786-3947, 1customercare@tasconline.com or www.partners.tasconline.com/etfemployee. Or review the UW System 2020 Vendor Change webpage.
Plan documents
EZ Enrollment Form
Paper Applications
Salary Reduction Agreement
Other Resources
WDC accounts can be managed online or over the phone.
The following can be found on the WDC website without logging in:
After you log into your WDC account, employees may:
- Submit or change their beneficiary
- Take advantage of the Special Catch-up provision
- Consolidate accounts
- Update your account information, such as address, username, and password
Employees may also call WDC for the forms. WDC representatives are available Monday-Friday between 7 a.m. and 9 p.m., and Saturdays between 8 a.m. and 4 p.m. at 1-877-457-9327. Press 0 and follow the prompts to speak to a representative. For local assistance in Madison, answer ‘yes’ to the prompts Monday through Friday between 8 a.m. and 4:30 p.m. Employees may also contact the WDC at wdcquestions@empower-retirement.com.
Visit the Edvest website for forms.
- – Complete and submit this form to your institution to request W/FMLA-protected leave. If you request a WFMLA leave to care for a domestic partner or a domestic partner’s parent, you must complete this form to certify the domestic partnership for WFMLA purposes.
- – Your health care provider must complete this form to certify your serious health condition if you take a concurrent FMLA and WFMLA leave. If you take a WFMLA leave only, use the WFMLA Certification form (UWS 82a) to certify your own serious health condition.
- – If you take a WFMLA leave only, use this form to certify your own serious health condition.
- – Your family member’s health care provider must complete this form to certify their serious health condition if you take a concurrent FMLA and WFMLA leave. If you take a WFMLA leave only, use the WFMLA Certification form (UWS 83a) to certify your family member’s serious health condition.
- – If you take a WFMLA leave only, use this form to certify your family member’s serious health condition.
- – Complete and submit this form to your institution to certify an exigency was created because a family member is on covered active military duty or has been notified of an impending call or order to active duty to a foreign country or international waters. The family member may be in either the regular or reserve component of the Armed Forces.
- – Complete and submit this form to your institution to request FMLA-protected leave to care for a current military service member, who is a family member or next of kin, who is seriously ill or injured due to military service.
- – Complete and submit this form to your institution to request FMLA-protected leave to care for a veteran, who is a family member or next of kin, who is seriously ill or injured due to military service.
last updated: 09/27/19
Every effort has been made to ensure this information is current and correct. This page does not guarantee enrollment or the ability to make changes to your benefits.
If you need to update your payroll direct deposit or your W-4 withholding, complete these forms and submit them to the human resources office at your institution.
- (Active employees can update their W-4 elections in Self Service. Log into the MyUW Portal and under the Payroll Information tile click on Update W-4.)
Updated: 08/27/2020