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.

 

 

 

 

 

 

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

Terms & Conditions

Each of the offered benefit plans includes the plan’s Terms and Conditions provision as part of the contract.  These provisions are typically included on the paper enrollment application for the plan. By signing the paper application or by submitting your enrollment elections via Benefits 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 and/or belief, the agreement to have premiums deducted from payroll and to cooperate during the plan’s investigation of the claim.

If you wish to review the Terms and Conditions of any of the benefit plans, the applicable contract language and/or a link to the plans’ provision are provided below.

More information about all of the benefit plans can be found at https://www.wisconsin.edu/ohrwd/benefits/, including plans’ certificates of coverage and other documents.

State Group Health Insurance

See the Terms and Conditions on pages 3 and 4 of the health insurance application, ET-2301.

Dental Wisconsin

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.

EPIC Benefits+

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.

 VSP Vision Insurance

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.

Employee Reimbursement Account

See the Terms and Conditions.

Health Savings Account

See the Terms and Conditions.

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 and Family Life Insurance

I understand that Wis. Stats §943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form and herby 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.

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 and Dismemberment (AD&D)

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.

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.

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

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

Deferred Compensation 457 Plan

See Wisconsin Plan and Trust Document.


last updated: 10/18/16