UW Benefits Forms & Publications

Insurance

CERTIFICATION FORMS

• Dependents with Disabilities - Use this form to request certification of a disabled dependent:
  • For certification starting in the 2009 plan year
  • For the 2010 plan year
• Extended (legal) Dependents - Use this form to request certification of a dependent child who is not yours through birth, adoption, marriage, or a qualified domestic partnership:
  • For certification starting in the 2009 plan year
  • For the 2010 plan year
• Qualified Domestic Partner (QDP) - To add your qualified domestic partner to your plan:
• During the 2009 plan year, complete both forms:
  Certification Form AND Medical/Dental Enrollment Form
• During the 2010 plan year, complete both forms:
  Tax Status Form AND Medical/Dental Enrollment Form
• Spouse - To add your spouse to your plan:
• During the 2009 plan year, complete both forms:
  Certification Form AND Medical/Dental Enrollment Form
• During the 2010 plan year, complete this form only:
  Medical/Dental Enrollment Form
• Student Certification/Change - For students age 20 - 23 attending an accredited school.
• Non-Smoker Certification

GENERAL FORMS

• Authorization of Release of Information
• Electronic Debit Service - For PEBB retirees and individuals enrolled in COBRA or self-pay insurance:
  • For deductions starting in the 2009 plan year
  • For the 2010 plan year
• Flexible Spending Account - See "Savings" forms below.
• Request to Cancel Dependent Coverage Form

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ADULT DEPENDENT COVERAGE

• Adult Dependent Enrollment/Change - Use this form for non-student dependents age 20-24:
  • For coverage starting in the 2009 plan year
  • For the 2010 plan year
  Electronic Debit Service - For individuals enrolled in adult dependent coverage:
  • For deductions starting in the 2009 plan year
  • For the 2010 plan year
  Request to Cancel Dependent Coverage

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COBRA—CONTINUATION OF COVERAGE ELECTION

• COBRA Continuation or Extension of Coverage - Use this form to continue coverage after loss of eligibility:
• For coverage starting in the 2009 plan year
• For the 2010 plan year
• (Note: if you have a child age 20-24 who is not a student, he or she may qualify for PEBB adult dependent coverage. See the Adult Dependent Enrollment/Change form.)
• Electronic Debit Service - For individuals enrolled in COBRA:
  • For deductions starting in the 2009 plan year
  • For the 2010 plan year

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  GRADUATE APPOINTEE INSURANCE PROGRAM (GAIP)

  • Reduced Enrollment Petition Form
  • Declaration of Marriage/Same-Sex Domestic Partnership (SSDP) Form—for GAIP only
  • Declaration of Tax Status for SSDP
  • Declaration of Tax Status Worksheet - for Determining Dependent Status
  • GAIP Medical/Dental/Vision Claim
  • GAIP Prescription Drug Claim
  • Generic ID Card
  • Mail Order Patient Registration (First read Mailing Agreement)
  • Petition for Self-Pay Graduate Appointee Insurance While on Academic Leave
  • Address/Name Changes - Update in:
    • Employee Self Service (ESS) and
    • Welfare and Pension Administration Service (WPAS)
  • Medical Summary
  • Dental Summary
  • Vision Summary

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  LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE

  • Address and/or Name Changes - Update in Employee Self Service (ESS)
  • Life Insurance Enrollment Form - For first-time enrollment
  • Life Insurance Enrollment Video - Instructions for first-time enrollees (9-min video)
  • Life Insurance Change Form - For current enrollees who want to change their enrollment
  • Life Insurance Change Video - Instructions for current enrollees (8-min. video)
  • Beneficiary Change
  • Life Insurance Conversion - For separating or retiring employees
  • Evidence of Insurability - Submit with Life/AD&D Enrollment form (above)
  • Non-Smoker Certification

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  LONG TERM DISABILITY (LTD) INSURANCE

  • LTD Enrollment/Change form (PEBB) for faculty/staff Complete and return to Benefits Office.
  • Evidence of LTD Insurability (PEBB) For eligible faculty/staff only.
  • Long Term Disability for Residents & Senior Fellows in the School of Medicine:
  • Dental Student LTD Application form For dental students who wish to purchase optional LTD insurance during the first 31 days of eligibility. Send the form to plan administrator, Professional Benefit Consultants, Inc. with the check payable to Standard Insurance MPA Program.
  • Medical Student LTD Application form For medical students who wish to purchase optional LTD insurance during the first 31 days of eligibility. Send the form to plan administrator, Professional Benefit Consultants, Inc. with the check payable to Standard Insurance MPA Program.
  • Medical Residents & Senior Fellows LTD Application form For medical residents and senior fellows who wish to purchase optional LTD insurance. Deadline for online submission is July 31.
  • Medical Residents & Senior Fellows LTD Conversion form To continue optional LTD insurance after residency or fellowship is completed. Submit online only.
  • Physician Assistants LTD Application form This insurance is available only to students enrolled in the MEDEX Northwest Physician Assistant Program.

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  MEDICAL AND DENTAL INSURANCE FOR FACULTY & STAFF

  • Please keep your name and address updated in Employee Self Service (ESS).
  • Medical and Dental Insurance Enrollment/Change - Faculty and staff can use this form to enroll or make changes to PEBB coverage.
    • For coverage starting in the 2009 plan year
    • For the 2010 plan year
  • Medical Plans—Claim forms for medical plans are available via the plan's website:
  • Aetna Public Employees Plan
  • Group Health Classic
  • Group Health Value
  • Kaiser Permanente Classic
  • Kaiser Permanente Value
  • Uniform Medical Plan
  • Uniform Medical Plan Mail-Order Prescriptions (Express Scripts)
  • Dental Plans:
  • DeltaCare - Group number 3100. This is Washington Dental Service's managed care plan.
  • Willamette Dental of Washington - This is Columbia Dental Group's pre-paid dental plan.
  • Uniform Dental Plan website (Delta Dental) Group number 3000. This is Washington Dental Service's fee-for-service plan with a preferred provider option.

  See Certification Forms above for Disabled Dependent Certification, Extended (legal) Dependent Certification (including foster children), Spouse or Qualified Domestic Partner Certification, or Student Certification.

  For Adult Dependent forms, see above.

  For Flexible Spending Account forms, see below.

  For Retiree Medical & Dental Coverage forms, see below.

  For a Section 125 Medical Plan Waiver form, contact the Benefits & Work/Life Office.

  Request to Cancel Dependent Coverage Form

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  SELF-PAY INSURANCE

  • Medical, Dental, Life & LTD Self-Pay Enrollment/Change - continuation of coverage for faculty and staff while on leave without pay.
  • For coverage starting in the 2009 plan year
  • For the 2010 plan year
  • Electronic Debit Service - For individuals enrolled in self-pay insurance:
  • For deductions starting in the 2009 plan year
  • For the 2010 plan year>
  • Self-Pay Rates

  Investment

  • Calvert Enrollment Website
  • Dependent Care Assistance Program - Go to Savings forms below.
  • Fidelity Enrollment website Use VIP plan ID number 87238
  • TIAA-CREF Enrollment website Use enrollment code VIP0331 for employee ID
  • Vanguard VIP Enrollment form
  • VIP Enrollment website
    • Address and/or Name Changes - Update with fund sponsor(s)
    • VIP Brochure
    • VIP Cancellation Form
    • VIP Enrollment Form

  Retirement

  GENERAL FORMS

  • Address and/or Name Changes - Update in Employee Self-Service (ESS)
  • Beneficiary Designation or Change This form is for DRS participants (PERS, TRS, LEOFF plans).
  • LAW ENFORCEMENT OFFICERS & FIRE FIGHTERS INSURANCE (LEOFF)
    • LEOFF Enrollment Form Return completed form to the Benefits Office.
  • PUBLIC EMPLOYEES RETIREMENT SYSTEM (PERS)
    • PERS Enrollment/Member Information Form For plan, contribution rate and investment program selection.
    • PERS Plan 3 - Change of Investment Program form
      Plan 3 members can use this form to choose an investment program that is either self-directed or through the Washington State Investment Board.
    • PERS Ineligibility Statement Use to be classified personally ineligible for PERS membership and to waive any claim to pension, annuity or disability benefits OR you are a retiree of another State Retirement System.
    • Rehiring PERS Retirees - Request for Approval For employing department use only.
    • Withdrawal of Retirement Plan Contributions For PERS Plan 1 and 2 members who have terminated retirement covered-employment and who are eligible for withdrawal of contributions and interest earned. When completing the request to withdraw your contributions, members need to also complete an IRS form W-9 to verify Social Security Number prior to payment.
    • Withdrawal of Retirement Contributions Instructions and form for requesting payment of defined contribution funds from PERS Plan 3.
  • TEACHERS RETIREMENT SYSTEM (TRS)
    • TRS Enrollment/Member Information Form
    • Rehiring TRS Retirees - Request for Approval For employing department use only.
  • UNIVERSITY OF WASHINGTON RETIREMENT PLAN (UWRP)
    • UWRP Enrollment/Change Form
    • Address/Name Changes - Update directly with your fund sponsor(s)
    • Beneficiary Designation or Changes - Contact your fund sponsor(s) for the appropriate form.
    • UWRP Increased Contribution For individuals age 50+ wanting to make additional contributions.
    • Vanguard UWRP Enrollment form

  Retiree Forms

  • Authorization for Direct Deposit For PERS, LEOFF or TRS retirees only: For all retirement benefit payments from DRS.
  • Electronic Debit Service - For faculty and staff retirees:
  • For deductions starting in the 2009 plan year
  • For the 2010 plan year
  • Medical & Dental Coverage Election - For faculty and staff retirees:
    • For coverage starting in the 2009 plan year
    • For the 2010 plan year
  • Other 2010 Medical & Dental Enrollment forms for retirees
  • Employment of PERS or TRS Retiree, Request for Approval For employing department use only.
  • Name/Address Changes For retirees of DRS plans (LEOFF, PERS, TRS)
  • Name/Address Changes for retirees of UWRP plan - Update directly with your fund sponsor(s).
  • Replacement Retiree ID card request To receive a replacement of a lost or stolen card
  • Retirement Status For re-employed retirees.
  • Statement Concerning Your Employment in a Job Not Covered by Social Security - For re-employed DRS or UWRP retirees.

  Savings

  DEPENDENT CARE ASSISTANCE PROGRAM (DCAP)

  Mail DCAP forms directly to: ASIFlex, PO Box 6044, Columbia, MO 65205-6044 or fax to 1-866-381-9682.

  • DCAP Reimbursement Claim
  • 2010 DCAP Plan Year Enrollment Form - To enroll or re-enroll for 2009 or for a qualifying change in family status.
  • 2009 DCAP Plan Year Enrollment Form - For new employees during 2009.
  • Claim Forms
  • Change of Election Form
  • Direct Deposit/Email Notification Form
  • 2009 DCAP Summary & Overview

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  FLEXIBLE SPENDING ACCOUNT

  Return FSA forms directly to: ASIFlex, PO Box 6044, Columbia, MO 65205-6044 or fax (toll-free) to: 1-866-381-9682

  • ASI Customer Service website
  • 2010 FSA Plan Year Enrollment Form
  • 2009 FSA Plan Year Enrollment Form
  • Claim Forms
  • Change of Election Form
  • Direct Deposit/Email Notification Form
  • Flex Debit Card Overview and Application
  • HIPAA Release of Information Waiver
  • Letter of Medical Necessity
  • 2009 FSA Summary & Overview
  • FSA Tax Saving Calculator
  • FSA Summary & Worksheet

  Miscellaneous

  • Authorization for Direct Deposit For PERS, LEOFF or TRS retirees only: Use this form for all retirement benefit payments from DRS.
  • City of Seattle Domestic Partnership Registration This is an application form to voluntarily register a domestic partnership with the City of Seattle.
  • Childcare Waitlist Application Use this application to be placed on a wait list for UW Children's Centers.
  • Pre-Tax Transportation Deduction Waiver to waive your participation in this pre-tax plan, complete this form and mail to the Benefits & Work/Life Office.
  • Section 125 Waiver - Read about the Section 125 Plan before deciding whether to waive participation in the state-sponsored Benefits Contribution Plan. (The Section 125 Medical Plan Waiver form is linked from the Plan page.)

  Special Request

  (for forms not listed above)

  Describe Your Request
  

  Complete the following information before clicking the 'Send Request' button:

  Your email address:

  Your name:

  Your UW campus mailbox:

  Your UW department:

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