Each of the benefits plans includes the Terms and Conditions as part of the contract. The provisions are typically included on the paper enrollment form for the plan. By signing the paper enrollment form or by submitting your elections via Self Service, you are agreeing to the Terms and Conditions of the plans in which you enroll.

The Terms and Conditions are provisions included in the insurance policy that place limitations on the insurer’s promise to pay or perform. These may include rules of conduct, duties and obligations for the member. If the policy conditions are not met, the insurer can deny the claim.

Common conditions in a policy may include the statement that all information is correct to the best of the applicant’s knowledge, the agreement to have premiums deducted from payroll and to cooperate during a plan’s claims investigation.

If you wish to review the Terms and Conditions of any of the plans, see the applicable language or a link to the provisions below.

More information about the benefits plans can be found at www.wisconsin.edu/ohrwd/benefits/ (including plan certificates of coverage).

State Group Health Insurance

See the Terms and Conditions section in the Health Insurance Application/Change form, ET-2301.

Dental Insurance (Delta Dental)

I apply for the coverage elected above. I understand that Wis. Stats. §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the information is true and correct. I agree to the provisions of the plan and hereby authorize deduction of the monthly premium.

Vision Insurance (VSP)

By signing below, I agree that all information is true. I understand that I am enrolling in a voluntary plan and that VSP will automatically deduct the entire monthly vision premiums from my paycheck. I agree to continue enrollment in the vision plan through December 31 of the current calendar year. To cancel my coverage, I must submit a request for cancellation prior to December 1 of the current year to cancel coverage beginning January 1 of the following year.

State Group Life Insurance

I understand that Wis. Stat. §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the information is true and correct.

Individual & Family Life Insurance

I understand that Wis. Stats §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the information is true and correct. I agree to the provisions of the plan and hereby authorize deduction of the monthly premium from my salary.

UW Employees, Inc. Life Insurance

I authorize my employer to make these change(s) and to withdraw any premiums from my salary to pay for supplemental insurance coverage.

University Insurance Association (UIA) Life Insurance

Any statements made in your application as defined in this certificate will be considered representations not warranties. Also, any statement made will not be used to void your insurance nor defend against a claim unless the statement is contained in the application attached to your certificate.

This certificate is issued in consideration of your application and payment of the required premium.

Accidental Death & Dismemberment (AD&D) Insurance

I understand that Wis. Stats §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the information is true and correct. I agree to the provisions of the plan and hereby authorize deductions of the monthly premium from my salary.

Accident Insurance (new plan effective January 1, 2020)
I understand that Securian Life Insurance Company shall incur no liability until the first premium is paid, and that premiums for the contributory insurance will be deducted from my pay. The information is true and complete to the best of my knowledge and belief. I have reviewed all applicable eligibility requirements for the coverage(s) I have elected and certify all such requirements have been met.

Income Continuation Insurance

I understand that Wis. Stat. §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the above information is true and correct. I authorize the monthly employee share premium deduction (indicated below) from my earnings to provide ICI and Supplemental ICI coverage (if selected). I understand that if premiums are not deducted, I do not have ICI coverage.

Employee Reimbursement Account (Flexible Spending Accounts)

2019 Terms and Conditions

2020 Terms and Conditions

Health Savings Account

2019 Terms and Conditions

2020 Terms and Conditions

UW Tax-Sheltered Annuity (TSA) 403(b) Plan 

See the Terms and Conditions on the Salary Reduction Agreement, form UWS-31.

Wisconsin Deferred Compensation (WDC) 457 Plan

See Wisconsin Plan and Trust Document.


last updated: 09/17/2019

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.