UW Benefits Forms & Publications

UNLESS OTHERWISE NOTED ON THE FORM, return completed forms to:
Benefits & WorkLife, UW Mailbox 355660, 3903 Brooklyn Ave NE, Seattle, WA 98105-6694.

Be sure to make a copy of each form for your own records before submitting it.

Form Categories

Insurance
Investment
Retirement

Retirees
Miscellaneous
Savings
Special Request

Insurance

GENERAL FORMS

Authorization of Release of Information
Declaration of Marriage/Qualified Domestic Partnership & Tax Status Form To add a spouse or qualified domestic partner to your plan. Must also complete Medical/Dental Enrollment form.
Dependent Certifications - For spouse, qualified domestic partner, students, children and other legal dependents (see below).
Electronic Debit Service For PEBB retirees and individuals enrolled in COBRA or self-pay insurance.
Flexible Spending Account - Go to Savings forms below.

COBRA—CONTINUATION OF COVERAGE ELECTION

DEPENDENT CERTIFICATION

Spouse or Qualified Domestic Partner Certification - To add a spouse or qualified domestic partner to your plan. Must also complete Medical/Dental Enrollment form.
Student Certification/Change
Dependents with Disabilities
Extended (legal) Dependents - For a dependent child who is not yours through birth, adoption, marriage, or a qualified domestic partnership.

GRADUATE APPOINTEE INSURANCE PROGRAM (GAIP)
LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE

Address and/or Name Changes - Update in Employee Self Service (ESS)
Life Insurance Enrollment - For first-time enrollment
Life Insurance Change Form
Beneficiary Change
Life Insurance Conversion - For separating or retiring employees
Evidence of Insurability - Submit with Life/AD&D Enrollment form (above)
Non-Smoker Certification

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.

MEDICAL AND DENTAL INSURANCE
Medical & Dental Insurance Enrollment/Change
Faculty and staff can use this form to enroll or make changes to your 2008 PEBB coverage.

Address and/or Name Changes - Update in Employee Self Service (ESS)
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
- 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.
Disabled Dependent Certification Use this form to request certification of a disabled dependent.
Flexible Spending Account forms
Foster Children, adding to your plan - See extended dependent
Retiree Medical & Dental Coverage form
Section 125 Medical Plan Waiver form - Request this form from the Benefits & Work/Life Office.
Student Certification/Change form
Uniform Medical Plan Mail-Order Prescriptions (Express Scripts)

Public Employees Benefits Board Partnership Registration

SELF-PAY INSURANCE

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 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.

Teachers Retirement System (TRS):

TRS Enrollment 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 PEBB retirees and individuals enrolled in COBRA or self-pay insurance.
Medical & Dental Coverage Election Form For faculty/staff Retirees
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) for 2008 Tax Year
Mail 2008 DCAP forms directly to: ASIFlex, PO Box 6044, Columbia, MO 65205-6044 or fax to 1-866-381-9682.
- 2008 DCAP Brochure
- 2008 DCAP Enrollment - New enrollment or a qualifying change in family status.
- 2008 DCAP Reimbursement Claim
FLEXIBLE SPENDING ACCOUNT for 2008 Tax Year
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
- All FSA forms - Claim forms, direct deposit, email notification, and release of information forms.
- FSA Change Form, 2008 - available soon
- FSA Claim form, 2008 - available soon
- FSA Enrollment form, 2008 - or enroll online at www.asiflex.com/pebb
- FSA Debit Card Application
- FSA Direct Deposit
- FSA Tax Saving Calculator
- FSA Sample Letter of Medical Necessity for potentially eligible expenses.
- FSA Summary & Worksheet, 2008

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)