Employee and Employer/Administrator Payroll and Benefits Forms

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Please consult your Payroll and Benefits Office if you have benefit eligibility questions or need assistance with any of the forms or publications found on this page. For benefit questions please contact benefits@ohr.wisc.edu

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New Employee Forms

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State Group Health Insurance

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EPIC Benefits+

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Dental Wisconsin Insurance

VSP Vision Insurance

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Flexible Spending Accounts (FSA)

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Income Continuation Insurance (ICI)

Income Continuation Insurance Plan Page

Publications


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.

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State Group Life Insurance

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Individual and Family Group Life Insurance

Individual and Family Group Life Plan Page

Publications



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

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University Insurance Association Life Insurance (UIA)

UW Employees Inc. Life Insurance

UW Employees, Inc. Life Plan Page

Publications


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

Evidence of Insurability

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

Conversion Application | Submit to Minnesota Life Insurance

Conversion Application

Beneficiary Designation | Submit to Minnesota Life Insurance

Beneficiary Designation

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Accidental Death and Dismemberment Insurance (AD&D)

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Wisconsin Retirement System (WRS)

ETF WRS Benefit Summary

Publications




Military Service Credit
Group Life Insurance After You Terminate Employment

Employee Forms


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

USERRA Certification Form, ET-4560

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

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.

Authorization to Disclose Non-Medical Information

Authorization to Disclose Non-Medical Individual Personal Information, ET-7406

Limited Power-of-Attorney for Appeal

Limited Power-of-Attorney For Appeal, ET-4944

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Tax Sheltered Annuity 403(b) Program (TSA)

Wisconsin Deferred Compensation (WDC)

Wisconsin Deferred Compensation Program Page

Publications


Employee Forms


Submit all forms to:

Wisconsin Deferred Compensation
5325 Wall Street, Suite 2755
Madison, WI 53718

Enrollment

If you have any questions, feel free to contact the WDC office directly at wdcprogram@gwrs.com or (877) 457-9327, option 2.

Catch-Up Contribution Application

Governmental 457(b) Application for Catch-Up

Beneficiary Designation

Beneficiary Designation

Incoming Rollover/Transfer

Incoming Transfer/Direct Rollover

Personal Information Change Request

Personal Information Change Request

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EdVest

EdVest Menu

Publications


Publications


Employee Forms


Submit all forms to:

EdVest College Savings Plan
P.O. Box 55189
Boston, MA 02205-5189

Enrollment

Note: No payroll deduction can be taken for EdVest.

Additional Investments

Additional Contribution Form

Beneficiary Designation

Change of Plan Owner/Beneficiary Form

Home Address, Bank, Contribution Change

Account Information Change Form

Rollover

Incoming Rollover Form

Additional forms can be found on the EdVest forms page.

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Leave Benefits

Long Term Care Insurance

Pre-Tax Transportation

Transportation Services

Employee Forms


Commuter Benefits—Enrollment/Change

Request for Reimbursement

Parking Enrollment/Change

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Finance

Finance Home

Employer/Administrator Forms


Direct Retro Funding Distribution

Direct Retro Funding Distribution

Funding Data Form

Funding Data Form

Human Resources

JEMS

JEMS Home

Employer/Administrator Forms


Add New CP/CJ/CL

Add New CP/CJ/CL

Add New ET/SA/OT/$0

Add New ET/SA/OT/$0

Add New FA/LI/AS

Add New FA/LI/AS

Payroll

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Time and Absence

Taxes

Domestic Partnership

General Employer/Administrator Resources

Employer/Administrator Forms


New Employee Packet

New Employee Packet, 2015

Notice of Benefit Eligibility

Notice of Benefit Eligibility, UW1030

Insurance Continuation or Cancellation Intention While on Unpaid Leave of Absence

Insurance Continuation or Cancellation Intention While on Unpaid Leave of Absence

Check Correction

Payroll Check Correction

Direct Deposit Authorization

Direct Deposit Authorization

Missed Payroll Request

Premium Waiver Request (State Group Life)

Premium Waiver Request, ET-5306

Salary Advance Request

Salary Advance Request, UW1275

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