Overview
Benefit applications, forms, and resources for each benefit plan can be accessed below.
Submit completed applications to your benefits contact.
Forms & Resources
Forms
Resources
- 2024 Health Benefits Decision Guide
- 2025 Health Benefits Decision Guide
- Glossary of Health Coverage and Medical Terms
- Guide to Office Visit Copays
- How to Choose Your Health Insurance Plan
- How to Get Care When You Need It eLearning (ETF)
- Patient Rights and Responsibilities
- Plan Design Options eLearning (ETF)
- Preventive Care Services Covered
- State & Federal Notifications
- Summary of Benefits & Coverage
- Terms and Conditions
- Affordable Care Act (ACA)
- Health Insurance Marketplace Notice
Certificate of Coverage
Plan Administrators
- State Group Health Insurance: Department of Employee Trust Funds | (877) 533-5020
- Pharmacy Benefits: Navitus Health Solutions | (866) 333-2757
- Well Wisconsin Program: WebMD | (800) 821-6591
- Terms and Conditions
- DeltaVision/EyeMed | (855) 544-6035 | Find a Provider (Insight Network)
- State Group Life Insurance Application/Cancellation/Refusal (ET-2304)
- State Group Life Insurance Certificate of Coverage (ET-2101)
- State Group Life Insurance Living Benefits Brochure (ET-2327)
- State Group Life Insurance Medical Evidence of Insurability Form (ET-2305)
- Conversion Form: Contact UW-Shared Services, Service Operations at serviceoperations@support.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- Continuation Form: Reach out to your benefits contact if you need a continuation form (continuation at retirement is automatic).
- Conversion Form: Contact UW-Shared Services, Service Operations at serviceoperations@support.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
The UW Employees, Inc. Board has decided to terminate the UW Employees, Inc. Life Insurance Plan effective January 1, 2025. Employees enrolled in the plan as of December 31, 2023 will be provided coverage through December 31, 2024. Group coverage in the UW Employees, Inc. Life Insurance plan will end January 1, 2025.
- Conversion Form: Contact UW-Shared Services, Service Operations at serviceoperations@support.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
The Universities of Wisconsin made a decision to terminate the University Insurance Association Life Insurance Plan effective January 1, 2025. Employees and continuants enrolled in the Plan as of January 1, 2024, will have coverage through December 31, 2024. Group coverage will end January 1, 2025.
- Conversion Form: Contact UW-Shared Services, Service Operations at serviceoperations@support.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a conversion form.
- (Policy number is GTU8364005)
- Continuation and Conversion Forms: Contact UW-Shared Services, Service Operations at serviceoperations@support.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) to obtain a continuation or conversion form.
- Continuation Form: Contact UW-Shared Services, Service Operations at serviceoperations@support.wisconsin.edu or (888) 298-0141 (7:45-4:30 p.m. Monday-Friday) if you need a continuation form.
- Terms and Conditions
- Securian | (866) 295-8690
Flexible Spending Accounts (FSAs)
- Automatic Premium Conversion Waiver (ET-2340)
- IRS Publication 502: Medical and Dental Expenses
- Healthcare FSA Unsubstantiated Claims Process web page
Health Savings Accounts (HSAs)
An HSA is available to individuals enrolled in a High Deductible Health Plan (HDHP) through the Universities of Wisconsin; it is a required component of the HDHP.
- 2025 HSA Enrollment Form
- IRS Publication 969: Health Savings Accounts and Other Tax-Favored Health Plans
- Automatic Premium Conversion Waiver (ET-2340)
Plan Administrator
- Optum | (833) 881-8158
- WRS Fact Sheet (ET-8901)
- Benefit Handbook (ET-2119)
- Variable Trust Fund Brochure (ET-4930)
- Election to Participate in the Variable Fund (ET-2356)
- Canceling Variable Participation (ET-2313)
- Additional Contributions Brochure (ET-2123)
- Maximum Additional Contribution Worksheet (ET-2566)
- Buying Creditable Services Brochure (ET-4121)
- Buying Other Governmental Service Brochure (ET-2207)
- Separation Benefits Brochure (ET-3101)
- WRS Guide to Retirement Brochure (ET-4133)
- Choosing an Annuity Option Brochure (ET-4117)
- Applying for Your Retirement Benefit Brochure (ET-4106)
- Calculating Your Retirement Benefits Brochure (ET-4107)
- ETF Retirement Estimate Request
- Retirement Estimate Request (ET-4207)
- Tax Liability on WRS Benefits (ET-4125)
- How Divorce Can Affect Your WRS Benefits Brochure (ET-4925)
- Disability Retirement Benefits Brochure (ET-5107)
- Duty Disability and Survivor Benefits Brochure (ET-5103)
- Death Benefits Brochure (ET-6101)
- Military Service and Your WRS Benefits
Plan documents
EZ Enrollment Form
Paper Applications
Salary Reduction Agreement
Resources
WDC accounts can be managed online, over the phone, or with a local WDC Retirement Plan Advisor.
- Online: www.wdc457.org
- The following can be found on the WDC website without logging in:
- After logging into your WDC account, you may:
- Update your contribution election
- Submit or change your beneficiary
- Consolidate accounts
- Aggregate your outside accounts to obtain your net worth and review your holistic financial picture
- Get help budgeting and/or information about emergency savings
- Review your probability of retiring when you want to
- Update your account information, such as address, username, and password
- After logging into your WDC account, you may:
- By Phone:
- WDC representatives are available Monday through Friday between 7 am and 9 pm, and Saturday between 8 am and 4:30 pm at (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 am and 4:30 pm.
- With a Retirement Plan Advisor:
- Schedule a virtual or in-person meeting with a WDC Retirement Plan Advisor. Go to wdc457.org then Schedule a Meeting in the bottom left-hand corner.
- Email:
Visit the Edvest website for forms.
If you would like to apply for the Public Service Loan Forgiveness Program, print and complete Sections 1 and 2 of the Public Service Loan Forgiveness Certification and Application. Submit the form along with the Public Service Loan Forgiveness Employer Verification Request to UW-Shared Services, Service Operations. Completed forms may be faxed to (608) 890-2327 or mailed to UW-Shared Services, Service Operations, 660 W. Washington Ave, Suite 201, Madison, WI 53703 (do not email 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.
- FMLA Guide for Employees
- FMLA Poster
- WFMLA Poster
Below are common payroll forms. Complete these forms by signing into my.wisconsin.edu or via paper. If a paper form is completed submit it to your human resources office.
- Direct Deposit
- Employee Self-Identification and W-4 Withholding Forms
- New Employees (paper forms):
- Current employees (use the my.wisconsin.edu):
For additional payroll information review the Payroll web page.
Beneficiary Designations
Remember to review and update your beneficiary designations when you have a life event to make sure that your benefits are paid according to your wishes. Benefit plans that have beneficiary designations include life insurance plans, retirement plans and the health savings account.
For more information review the Beneficiary Information web page.
Every effort has been made to ensure this information is current and correct. Information on this page does not guarantee enrollment, benefits and/or the ability to make changes to your benefits.