Forms and Publications

Employee Forms

Direct Deposit

Direct Deposit Authorization

W-4 Form Packet | Includes W-4 Employee's Withholding Allowance Certificate and Employee Self-Identification (Ethnicity and Heritage, Disability, and Veterans Survey)

Publications

It's Your Choice: 2013 Decision Guide

It's Your Choice: 2013 Reference Guide

Standard Plan

Decision Guide 2013 Corrections/Updates
Reference Guide 2013 Corrections/Updates
Employee Forms

Application | Submit to your Payroll & Benefits Office.
- Health Insurance Application/Change Form, ET-2301
- Tax Considerations: Imputed Income and Health Insurance Benefits
Affidavit for Non-citizen Insurance | Submit to your Payroll & Benefits Office
- Affidavit for Insurance Purposes, UWS 93
  Complete this form if you are unable to provide a Social Security Number for a non-citizen spouse or non-citizen eligible dependent. Submit the Affidavit with your application.
Authorization to Disclose Medical Information
Authorization to Disclose Medical Information, ET-7414
Health Insurance During Military Leave
Health Insurance Election For Military Service Personnel, ET-2350
Dependent Tax Status Change
Dependent Tax Status Change Form, UW1541
Complaint Form
Employee Trust Funds Complaint, ET-2405
Employer/Administrator Forms

Continuation Application
- Application for Continuation, ET-2311 (2013)
Tier 2 Eligibility
Eligibility for Standard Plan Tier 2 Premiums, UW1106
Domestic Partnership Processing Checklist
Domestic Partnership Processing Checklist

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Publications

2013 Benefits+ Brochure

Davis Vision Affinity Discount Program

Changes and FAQ

Certificate of Coverage
2013 Dental Plan Comparison Chart

Employee Forms

Application | Submit to your Payroll & Benefits Office
Benefits+ Enrollment Form
Affidavit for Insurance Purposes | Submit to your Payroll & Benefits Office
Affidavit for Insurance Purposes, UWS 93
Complete this form if you are unable to provide a Social Security Number for a non-citizen spouse or non-citizen eligible dependent. Submit the Affidavit with your application.

Beneficiary Designation | Submit to EPIC
Beneficiary Designation Form
Claims Forms

Hospital Indemnity/Outpatient Surgical Claim Form | Submit to EPIC
Hospital Indemnity/Outpatient Surgical Claim Form
Life, AD&D, Living/Accelerated Benefit Claim Form | Submit to EPIC
Life, AD&D, Living/Accelerated Benefit Claim Form
Davis Vision Claim Form | Submit to Davis Vision
Davis Vision Claim Form
Employer/Administrator Forms

Continuation Form
EPIC Benefits+ Continuation Form, E11472

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Publications

2013 Dental Wisconsin Brochure

Frequently Asked Questions

Certificate of Coverage
2013 Dental Plan Comparison Chart

Employee Forms

Application | Submit to your Payroll & Benefits Office
Dental Wisconsin Enrollment Form
Employer/Administrator Forms

Continuation Form
Dental Wisconsin Continuation Form, E13000

Publications

Plan Year 2013

Certificate of Coverage

Employee Forms

Application | Submit to your Payroll & Benefits Office
Vision Plan Application, UWS66
Employer/Administrator Forms

Continuation Form
Election of Continued Vision Coverage, UWS-67

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Important Changes to Employee Reimbursement Account (ERA) Program Effective July 1, 2012

Publications

Plan Year 2013 Booklet
Employee Forms

Application | Submit to your Payroll & Benefits Office
- ERA Enrollment Form, FBWW/WIS
  This form should be used by employees enrolling during the Annual Benefit Enrollment Period or new employees whose participation will begin on or after January 1, 2013.
Change In Status | Submit to Fringe Benefits Management Company
- Change In Status Form
- Change in Status Information
Reimbursement | Submit to WageWorks
- Dependent Care Account Claim Form
- Health Care Account Claim Form
Premium Conversion Waiver
Automatic Premium Conversion Waiver/Revocation Of Waiver
Employer/Administrator Forms

Continuation Form
Medical Expense Account Continuation Election Form, ET-1518
Medical Expense Account after termination
If you terminate employment or cease to be an eligible employee prior to the end of the plan year and do not arrange to continue your coverage, your coverage ends at the end of the month in which your last ERA payroll deduction was taken. Expenses for services provided to you after this date are not reimbursable.

Dependent Care Account after termination
If you terminate employment or cease to be an eligible employee prior to the end of the plan year, you cannot continue dependent care contributions. You can continue to request reimbursement for eligible expenses from your Dependent Care Account until you exhaust your account balance or March 15, whichever comes first, even if you have not contributed the full annual amount for which you enrolled. Valid expenses are those that are incurred for the care of a qualified dependent so that you (and your spouse) can work, look for work, or attend school full-time.

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Publications

Income Continuation Insurance

Employee Forms

Application | Submit to your Payroll & Benefits Office
Income Continuation Insurance Application, ET-2307
Evidence of Insurability | Submit to ETF
Evidence of Insurability, ET-2308
If you do not enroll for ICI coverage when you are first eligible, you can enroll only by completing an Evidence of Insurability application.

Sick Leave Usage | Submit to the Office of Human Resources, 21 N. Park St., Suite 5101
Sick Leave Usage Election at Time of Claim, UW1456
Complete this form only if you are applying for a WRS Disability annuity, an LTDI benefit, or a § 40.65 Duty Disability benefit from the Department of Employee Trust Funds at the same time that you are applying for Income Continuation Insurance benefits.
Employer/Administrator Forms

Employer Statement
Income Continuation Insurance (ICI) Employer Statement, ET-5351
Report of Employment Earnings
Report of Employment and Earnings, ET-5901

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Publications

Plan Booklet

Group Life Insurance After You Terminate Employment
Employee Forms

Application | Submit to your Payroll & Benefits Office
- Life Insurance Application / Cancellation / Refusal, ET-2304
Evidence of Insurability | Submit to Minnesota Life Insurance
Evidence of Insurability, ET-2305
If you do not enroll during your initial enrollment period, you may apply for coverage using this form.

Beneficiary Designation | Submit to ETF
Beneficiary Designation, ET-2320
Conversion | Submit to Minnesota Life Insurance
Conversion of Group Life Insurance Enrollment, ET-2306
Notice of Death
- Notice of Death, ET-6301
- Notice of Death for Spouse or Dependent Child, ET-6303
Employer/Administrator Forms

Continuation Application
Wisconsin Public Employers Group Life Insurance Program Continuation Application, ET-2154
Premium Waiver Request
Request for Disability Premium Waiver, ET-5306

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Publications

Individual and Family Group Term Life Insurance

Fact Sheet

Certificate of Insurance

Employee Forms

Application | Submit to your Payroll & Benefits Office
Application / Cancellation / Change Request, UWS 1301
Evidence of Insurability | Submit to Minnesota Life Insurance
Evidence of Insurability, 03-30538
If you do not enroll for coverage when you are first eligible or would like to increase your coverage beyond the annual increase option amount, you can apply by completing an Evidence of Insurability application.

Conversion Application | Submit to Minnesota Life Insurance
Conversion of Group Life Insurance Enrollment, 03-30573
Beneficiary Designation | Submit to UW System Administration
Beneficiary Designation, UWS 1305
Transfer of Ownership | Submit to Minnesota Life Insurance
Transfer of Ownership, F66318-2
Employer/Administrator Forms

Request for Disability Premium Waiver
Request to Initiate Disability Premium Waiver Claim, UWS-B1225

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Publications

Fact Sheet

Certificate of Insurance

Employee Forms

Conversion | Submit to Minnesota Life Insurance
Conversion of Group Life Insurance Enrollment, EdF68525
Beneficiary Designation | Submit to Minnesota Life Insurance
Beneficiary Designation, F59786
Living Benefit | Submit to Minnesota Life Insurance
Notice of Claim for Living Benefit, F45067
Transfer of Ownership | Submit to Minnesota Life Insurance
Transfer of Ownership, F66318-2
Employer/Administrator Forms

Continuation Application
Continuation Application/Ballot Request, UWS 1206

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Publications

Brochure

Certificate of Insurance

Employee Forms

Application | Submit to your Payroll & Benefits Office

Application for Enrollment or Cancellation

Coverage is effective on the first of the month after your Payroll & Benefits Office has received your application.

Evidence of Insurability | Submit to Minnesota Life Insurance Company

Evidence of Insurability

If you do not enroll during your initial enrollment period, you may apply for coverage using this form.

Employee Forms

Uniformed Services Employment and Reemployment Rights Act (USERRA) Certification Form

USERRA Certification Form, ET-4560

Affidavit of Employment with a WRS Participating Employer Prior to July 1, 2011

Affidavit of Employment with a Wisconsin Retirement System (WRS) Participating Employer Prior to July 1, 2011

Long-Term Disability Claim

Claim Filing Instructions for the Income Continuation Insurance (ICI) and Long-Term Disability Insurance (LTDI) Plans, ET-5106

Sick Leave Election

Sick Leave Election, UW1456

Additional Contribution Election

Beneficiary Designation

Beneficiary Designation, ET-2320

Benefit Information Request/Estimate

Benefit Information Request, ET-7301

Qualified Domestic Relations Order

Order to Divide Wisconsin Retirement System Benefits, ET-4926

Income Tax Withholding for Retirees

Income Tax Withholding Election, ET-4310

Rehired Annuitant Election

Rehired Annuitant Election, ET-2319

Election to Cancel Variable Participation

Canceling Variable Participation, ET-2313

Election to Participate in the Variable Trust Fund

Election to Participate in the Variable Trust Fund, ET-2356

Your Variable Trust Fund participation will become effective on the January 1 after the date your election is received. If you are a new WRS participant and ETF receives your Variable Trust Fund election form within 30 days after the date your WRS-covered employment begins, your election becomes effective immediately on the date your employment began.