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Forms and Publications

The following chart contains direct links to the forms and publications needed by employees or those needed by the campuses for reporting.

Employer Forms

Employee Forms - Pick the benefit plans below

Accidental Death & Dismemberment Long Term Care
Deferred Compensation Pre-Tax Transportation
Dental and Excess Medical Retirement
Dental-Represented and Non-Represented Savings Bonds
Employee Reimbursement Accounts (ERA) Savings--Edvest
Health Insurance Tax Sheltered Annuities
Income Continuation Insurance Taxes
Individual and Family Group Life Insurance University Insurance Assoc. Life Insurance
Leave Benefits UW Employees, Inc., Life Insurance
Life Insurance--State Group Vision Benefits

Accidental Death and Dismemberment (AD&D)

Title

Form No.

Print/Order

Application UWS1245 Online
Application - Continuation UW1249 Online
Application - Pilot Coverage  HRIS-B1247 Online
Application - Pilot History HRIS-B1248 Online
Beneficiary Designation UWS1245 Online
Certificate UWS-B1250 Online
Fact Sheet UWS1246 Online
Travel Assistance UWS1255 Online

Deferred Compensation

Title

Form No.

Print/Order

Application - Participant Enrollment Form NA www.wdc457.org or call the Madison Office at 877-457-9327, Option 2
Application - Withdrawl NA Call the Madison Office at 877-457-9327, Option 2
Beneficiary Designation NA Change your beneficiary on line by logging into your WDC account at www.wdc457.org or call the Madison Office at 877-457-9327, option 2 to obtain the form via mail or email
Catch-Up Election NA Call the Madison Office at 877-457-9327, Option 2
Fact Sheet NA www.wdc457.org
Investment Performance NA www.wdc457.org
Paricipation Agreement NA https://wisconsin.gwrs.com/static/Wisconsin/pdf/planhighlights.pdf
Payment Estimate NA Call the Madison Office at 877-457-9327, Option 2

Dental and Excess Medical (EPIC) 

Title

Form No.

Print/Order

Application E11444 Online
Application - Continuation E11472-0011 Online
Beneficiary Designation None Online
Brochure E11549-0309 Online

Dental--Represented and Non-Represented Plan 

Title

Form No. 

Print/Order

Application OSER/UW Application Online
Application - Continuation HRIS-1603 Online
Plan Summary DNTB-8373b Online
HMO Handbook DC-83445-7, -9999 Online
PPO Handbook DC-83445-8, -18 Online
Supplemental Handbook DC-83445-9, -19 Online
Provider Directory HMO STD-NEW/Ortho (Combo) Online
Provider Directory PPO HD-PPO/Ortho(Combo) Online

Employee Reimbusement Accounts (ERA)

Title

Form No. 

Print/Order

Application FBMC/WIS/0803 Online
Application - Continuation ET-1518 Online
Automastic Premium Conversion Waiver/Revocation of Waiver ET-2340 Online
Change in Status None Online
Claim None Online
Rapid Refund None Online

Health Insurance

Title

Form No. 

Print/Order

Application (Classified/Unclassified) ET-2301 Online
Application--Graduate Assistant ET-2302 Online
Application - Continuation ET-2311 Online
Authorization to Disclose Non-Medical Individual Personal Information ET-7406 Order
Complaint Form ET-2405 Online
Health Insurance Election for Military Personnel ET-2350 Online
Health Insurance Rate Addition to the Quick File UW1054 Online
It's Your Choice Booklet (Classified/Unclassified) ET-2107 Online
It's Your Choice Booklet (Graduate Assistant) ET-2127 Online
WPS Standard Plan Booklet ET-2112 Order

Income Continuation Insurance

Title

Form No. 

Print/Order

Application ET-2307 Online
Order
Application - Evidence of Insurability ET-2308 Online
Certificate/Booklet ET-2106 Online
Order
Employer Statement ET-5351 Online
Report of Employment Earnings ET-5901 Online
Sick Leave Election Usage UW1456 Online

Individual and Family Group Life Insurance

Title

Form No. 

Print/Order

Application 03-30539 Online
Application - Evidence of Insurability 03-30538 Online
Application - Conversion 03-30573 Online
Beneficiary Designation F 53232 Online
Conversion Brochure F4638-11 Online
Premium Waiver Request UWSB-1225-6 Online

Leave Benefits

Title

Form No. 

Print/Order

Classified Annual Leave Conversion Options (Non-Rep, WPEC Exempt, WSP Exempt, UPQHC, SEA, PERSA Exempt) UW1089 Online
Classified Annual Leave Conversion Options (WEAC) UW1250 Online
Classified Annual Leave Conversion Options (WLEA) UW1250 Online
Classified Annual Leave Conversion Options (WSEU, WPEC Non-Exempt, WSP Non-Exempt, and PERSA Non-Exempt) UW1250 Online
Unclassified Leave Accounting Request UW1397 Online

Life Insurance--State Group

Title

Form No. 

Print/Order

Application ET-2304 Online
Application - Evidence of Insurability ET-2305 Online
Application - Continuation ET-2154 Online
Application - Conversion ET-2306 Online
Beneficiary Designation ET-2320 Online
Certificate/Booklet ET-2101 Online
Limited Power of Attorney Appeal  ET-4944 Online

Long Term Care

Title

Form No.

Print/Order

Application None Online

Pre-Tax Transportation

Title

Form No. 

Print/Order

Commuter Benefits - Enrollment/Change None Online
Commuter Benefits - Request for Reimbursement None Online
Vanpool - Enrollment/Change None Order
Vanpool - Waiver (PDF) UW1079 Online

Retirement

Title

Form No. 

Print/Order

Additional Contributions ET-2123 Online
Beneficiary Designation ET-2320 Online
Buying Creditable Service ET-4121 Online
Calculating Your Retirement Benefits ET-4107 Online
Choosing an Annuity Option ET-4117 Online
Death Benefits ET-6101 Online
Disability Benefits ET-5102 Online
Group Health Insurance Book for Retirees ET-4112 Online
Group Life Ins. After You Terminate Employment ET-4104 Online
How Divorce Can Affect Your WRS Benefits ET-4925 Online
How Participation In The Variable Trust Fund Affects Your WRS Benefits ET-4930 Online
Information for Retirees ET-4116 Online
Military Service Credit ET-4122 Online
Rehired Annuitant Election ET-2319 Online
Separation Benefits ET-3101 Online
Tax Liability on WRS Benefits ET-4125 Online
Your Benefit Handbook ET-2119 Online

Savings Bonds 

Title

Form No. 

Print/Order

Authorization for Purchase and Request for Change-Series I None Online
Authorization for Purchase and Request for Change-Series EE None Online

Savings--EdVest

Title

Form No. 

Print/Order

EdVest Enrollment Kit None Order
Additional Investments None Online
Beneficiary Designation None Online
Distribution None Online
Home Address, Bank, Contribution Change None Online
Investment Change None Online
Rollover None Online
Successor Account (as Custodian) Owner Designation None Online

Tax Sheltered Annuities

Title

Form No. 

Print/Order

Beneficiary Designation None Order
Mistake of Fact UWS3250 Online
Salary Reduction Agreement (Printable and Fillable) HRIS-B3231 Online

Taxes 

Title

Form No. 

Print/Order

Duplicate W-2, 1042-S and Reportable Fellowship 1099 (Multiple Request) (Excel) UW1179 Online
Duplicate W-2, 1042-S and Reportable Fellowship 1099 (Single Request) UW1180 Online
Earned Income Credit - Wisconsin W-5 Online
Employee Campus/Home Address Change UW1035 Online
Employee's Withholding Agreement - Wisconsin  WT-4A Online
Employee's Withholding Allowance Certificate - Federal  W4 (UW1389) Online
International Tax Packet UW1469 Online
Statement of Minnesota Residency - Wisconsin 2007 W-222 Online
Statement of Minnesota Residency - Wisconsin 2008 W-222 Online
Working Families Tax Exemption - Wisconsin  WT-4B Online

University Insurance Association Life Insurance (UIA) 

Title

Form No. 

Print/Order

Application - Continuation UW1443-1 Online
Beneficiary Designation F. 59786 Online
Certificate 03-30564 Online

UW Employees, Inc. Life Insurance 

Title

Form No. 

Print/Order

Application GA-1314 Online
Application - Conversion None Online
Application - Evidence of Insurability GA-1129 Online
Beneficiary Designation GA-562 Online
Brochure GA-1117 Online
Certificate UW/GIC/05 Online

Vision Benefits

Title

Form No. 

Print/Order

Application  EF4t Online
Application - Continuation EF4t Online