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
- 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
Go to the Vision Insurance web page for information and resources on this program.
- 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)
- 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.
- (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.
Go to the Accident Insurance web page for information and resources on this program.
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.
- IRS Publication 969: Health Savings Accounts and Other Tax-Favored Health Plans
- Automatic Premium Conversion Waiver (ET-2340)
Plan Administrator
- Optum | (833) 881-8158
Go to the Wisconsin Retirement System web page for information and resources on this program.
Plan documents
EZ Enrollment Form
Paper Applications
Salary Reduction Agreement
Resources
Go to the Wisconsin Deferred Compensation (WDC) 457 Program web page for information and resources on this program.
Go to the 529 College Savings Plan web page for information and resources on this program.
Go to the Public Service Loan Forgiveness Program web page for information and resources on this program.
- - 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.
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.