Benefits - By Plan

 

 

 

Cost-sharing illustration: Health Plan vs HDHP options

 

 

 

Note:

If you are enrolling in the High Deductible Health Plan, you must enroll in the Health Savings Account. See Health Savings Account section for the enrollment form.

 

Complete and submit to EPIC Life Insurance Company to name who you would like to receive benefits payable upon your death under the Accidental Death and Dismemberment provision.

 

Complete and submit to EPIC Life Insurance Company to file a claim for an outpatient surgery or hospital confinement.

Complete and submit to Davis Vision to file a claim for vision services received out of the Davis Vision network.

 

 

Complete and submit to EPIC Life Insurance Company to file a claim for a death or dismemberment.

 

 

 

  • Health Savings Account Enrollment form
    Health Savings Account Enrollment form

    If you are enrolling in a High Deductible Health Plan through the State Group Health Insurance plan, you must enroll in the Health Savings Account. Complete this enrollment form and submit it along with your State Group Health enrollment form to your benefits office.

    Make sure to read through all pages of the enrollment form for detailed plan information and participant responsibility.

    If you are not enrolling in a High Deductible Health Plan, you are not eligible to enroll in the HSA.

  • HSA Distribution Request Form
    HSA Distribution Request Form

    Use this form to request a distribution (withdrawal) from your HSA.

 

 

 

Complete and submit to your institution’s benefits office to enroll in the plan.

 

 

Complete and submit to the Department of Employee Trust Funds (ETF) to name who you would like to receive benefits payable upon your death.

 

 

If you are terminally ill with a life expectancy of 12 months or less, read the Living Benefits Brochure to determine if you’d like to apply for living benefits.

 

 

Complete and submit to Securian if you want to convert your coverage to an individual policy at the end of employment. Your benefits office must complete the Employer Section before it is submitted to Securian.

 

 

Complete and submit to Securian if you want to apply for coverage through Evidence of Insurability. Your benefits office must complete the Employer Section before it is submitted to Securian.

 

 

  • Continuation Form – Contact your benefits office if you need a continuation form. Continuation at retirement is automatic.

 

  • Accelerated Death Benefit Form
    Accelerated Death Benefit Form

    Complete and submit to Securian if you have a terminal illness with a life expectancy of less than 12 months and want to apply for benefits payable during your lifetime. Your benefits office must complete the Employer Section before it is submitted to Securian.

  • Conversion Form
    Conversion Form

    Complete and submit to Securian if you want to convert your coverage to an individual policy at end of employment. Your benefits office must complete the Employer Section before it is submitted to Securian.

  • Medical Evidence of Insurability Form
    Medical Evidence of Insurability Form

    Complete and submit to Securian if you want to apply for coverage through Evidence of Insurability. Your benefits office must complete the Employer Section before it is submitted to Securian.

  • Beneficiary Designation
    Beneficiary Designation

    Complete and submit to UW System Administration to name who you would like to receive benefits payable upon your death.

Plan Administration

The Individual and Family Group Life Insurance plan (group policy #32871-G) is administered by University of Wisconsin System Administration and underwritten by Securian Financial Group.

  • Accelerated Death Benefit Form
    Accelerated Death Benefit Form

    Complete and submit to Securian if you have a terminal illness with a life expectancy of less than 12 months and want to apply for benefits payable during your lifetime. Your benefits office must complete the Employer Section before it is submitted to Securian.

  • Conversion Application
    Conversion Application

    Complete and submit to Securian if you want to convert your coverage to an individual policy at the end of employment. Your benefits office must complete the Employer Section before it is submitted to Securian.

  • Medical Evidence of Insurability Form
    Medical Evidence of Insurability Form

    Complete and submit to Securian if you want to apply for coverage through Evidence of Insurability. Your benefits office must complete the Employer Section before it is submitted to Securian.

 

Plan Administration

The UW Employees, Inc. Life Insurance Plan (group policy #33977-G) is administered by University of Wisconsin Employees Inc., an employee-directed nonprofit corporation. This plan is underwritten by Securian Financial Group.

  • Beneficiary Designation
    Beneficiary Designation

    Complete and submit to Securian to name who you would like to receive benefits payable upon your death.

  • Accelerated Benefit Form
    Accelerated Benefit Form

    Complete and submit to Securian if you have a terminal illness with a life expectancy of less than 12 months and want to apply for benefits payable during your lifetime.

  • Conversion Form
    Conversion Form

    Complete and submit to Securian if you want to convert your coverage. Your benefits office must complete the Employer Section before it is submitted to Securian.

 

Plan Administration

The University Insurance Association Life Insurance Plan (group policy #32872-G) is administered by the University Insurance Association Board. The plan is underwritten by the Security Financial Group.

  • Application
    Application

    Complete and submit to your institution's benefits office to enroll in the plan.

  • Beneficiary Designation
    Beneficiary Designation

    Complete and submit to UW System Administration to name who you would like to receive benefits payable upon your death.

  • Conversion Form
    Conversion Form

    Follow the instructions on the conversion bulletin to learn how to convert your group policy to an individual policy. Must be under age 70 to convert.

 

Plan Administration

The Accidental Death and Dismemberment Insurance plan (group policy #GTU 8364005) is administered by University of Wisconsin System Administration and Hausmann-Johnson Insurance and underwritten by Zurich American Insurance Company.

 

 

 

 

 

 

  • Application
    Application

    Complete and submit to your institution's benefits office to enroll in this plan.

Complete and submit to ETF if you want to apply for coverage or decrease your waiting period through Evidence of Insurability. Your benefits office must complete the Employer Section before it is submitted to ETF.

  • Sick Leave Usage During Disability Claim (UWS 430)
    Sick Leave Usage During Disability Claim (UWS 430)

    Complete this form only if you are applying for a WRS Disability annuity (40.63), a Long-Term Disability Insurance (LTDI) benefit or a Duty Disability benefit at the same time you are applying for an ICI benefit.

 

See Also