Benefits - By Plan

 

Forms

  • Affidavit for Insurance Purposes
    Affidavit for Insurance Purposes

    Complete and submit with your health insurance application if your covered family member is not a U.S. citizen and does not have a Social Security number.

  • HSA Beneficiary Form
    HSA Beneficiary Form

    Complete and submit to the HSA plan administrator to name who you would like to receive benefits payable upon your death.

  • HSA Enrollment Form
    HSA Enrollment Form

    If you are enrolling in the HDHP or Access HDHP, you must also be eligible for, and enroll, in the HSA. Complete and submit it along with your Health Insurance Application/Change form to your human resources office.

Resources

Certificate of Coverage

Health Savings Account (HSA)

only available to individuals who are eligible for the HSA and enroll in either the HDHP or Access HDHP plan design

Summary of Benefits & Coverage

Plan Administrators


last updated: 2/20/2017

See Also

Beneficiary Designations

What is a beneficiary?

A beneficiary is the person or entity you name in a life insurance policy or retirement plan to receive the benefit upon your death. The beneficiary designation on file at the time of your death is binding in the payment of your benefits.

Whenever there is a big life event, such as when you get married, divorced, have a child or a grandchild joins the family, you may want to review your beneficiary designations and update them if you wish. You can change your beneficiary at any time, in accordance with the plan requirements.

Beneficiary designation forms can be found below. Completed forms should be sent directly to the benefit plan, not to your human resources office. The address can be found below and on each beneficiary designation form.

Please retain a copy of your beneficiary designation forms for your records. The UW System does not process or store the beneficiary designation forms. Please contact the plan administrator directly for questions about your beneficiary designations.

If you don’t designate a beneficiary, your benefit will be paid out according to Wisconsin law. This is called Standard Sequence and will pay to beneficiaries as follows:

  • Your surviving spouse or domestic partner, otherwise;
  • Your surviving children equally, otherwise;
  • Your surviving grandchildren equally, otherwise;
  • Your surviving parents equally, otherwise;
  • Your surviving siblings equally, otherwise;
  • Your estate.

Note: All claims associated with the death of a covered family member will be paid to the employee.

Benefit plans with benefits that are payable to beneficiaries

Wisconsin Retirement System (WRS) and State Group Life Insurance

The WRS is administered by the Department of Employee Trust Funds (ETF). State Group Life Insurance is administered by the ETF and is underwritten by Securian Financial Group.

WRS and State Group Life Insurance share the same beneficiary designations.

If you prefer to name different beneficiaries for these two benefit plans, you must complete a separate beneficiary designation form for each benefit plan. At the bottom of the beneficiary designation form, there is a line where you can specify the benefit plan.

State Group Life Insurance Policy Number: 2832-G

Individual and Family Life Insurance

Administered by University of Wisconsin System Administration and underwritten by Securian Financial Group.

  • Beneficiary Designation Form
  • Mail completed form to: University of Wisconsin System, Human Resources & Workforce Diversity, 780 Regent Street, Suite 224, Madison, WI 53715

Group Policy Number: 32871-G

UW Employees, Inc Life Insurance

Administered by University of Wisconsin Employees Inc., an employee-directed nonprofit corporation, and is underwritten by Securian Financial Group.

  • Once you enroll in coverage, Securian will send you login information so you can name your beneficiary(ies) online through their secure LifeBenefits portal.
  • Beneficiary Designation Form – You can also mail a paper designation form directly to Minnesota Life Insurance Company (a Securian Company), Group Administration Department, 400 Robert Street North, St. Paul, MN 55101-2098 or fax to (651) 665-4827

Group Policy Number: 33977-G

University Insurance Association (UIA) Life Insurance

Administered by University Insurance Association Board and is underwritten by Securian Financial Group.

  • Beneficiary Designation Form
  • Mail completed form to: Minnesota Life Insurance Company (a Securian Company), P.O. Box 259708, Madison, WI 53725-9708 or fax to (608) 277-8665

Group Policy Number: 32872-G

Accidental Death and Dismemberment

Administered by University of Wisconsin System Administration and Hausmann-Johnson Insurance and underwritten by Zurich American Insurance Company.

  • Beneficiary Designation Form
  • Mail completed form to: University of Wisconsin System, Human Resources and Workforce Diversity, 780 Regent Street, Suite 224, Madison, WI 53715

Group Policy Number: GTU 8364005

EPIC Benefits+

Administered by EPIC Specialty Benefits.

  • Beneficiary Designation Form
  • Mail completed form to: The EPIC Life Insurance Company, Attention: Life & Disability Department, P.O. Box 8430, Madison, WI 53708-8430 or fax to (800) 236-7610

Group Policy Number: 318000

Tax-Sheltered Annuities 403(b) Program

The Tax-Sheltered Annuity (TSA) program is administered by the UW System Office of Human Resources and Workforce Diversity.  The TSA Review Committee provides oversight of the program.

Contact the investment companies to obtain a beneficiary designation form and/or to determine if the company is subject to the following Standard Sequence in absence of a beneficiary form.

Fidelity, T Rowe Price and TIAA allow participants to update beneficiary designations through their online investment account.

Current Provider Contact Information:

Frozen Provider Contact Information:

Wisconsin Deferred Compensation

The Wisconsin Deferred Compensation (WDC) program is administered by the Department of Employee Trust Funds (ETF) through a third-party administrator, Empower Retirement.

  • Once enrolled, a password is mailed to the address on file. You can use your social security number (username) and this password to access your account information online at www.wdc457.org. In addition, you may update your beneficiary(ies) online.
  • Beneficiary Designation Form – You can also mail a paper designation form directly to Empower Retirement, P.O. Box 173764, Denver, CO 80217-3764 or fax to (866) 745-5766.

Contact Information:

 Resources

 


last updated: 3/8/2017

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