UW Benefits Forms and Publications
Most Requested Forms

Faculty and staff: To enroll or make changes to your health insurance coverage during Open Enrollment (November 1–30) with changes going into effect on January 1, 2013:

• Download and complete the 2013 Enrollment/Change Form (PDF).
• Plus, if you are adding family members to your coverage, you must provide valid dependent verification to document their eligibility.
• Plus, if you are adding a qualified domestic partner to your coverage, you will need to provide a 2013 Declaration of Tax Status Form (PDF).

Download and complete this form:

• 2013 Life & Accidental Death & Dismemberment (AD&D) Insurance Enrollment/Change Form (PDF)
  

In addition, submit the 2013 Evidence of Insurability (EOI) Form if you are:

• a newly-eligible employee who applies after the initial 60-day deadline for guarantee-issue coverage, OR
• a PEBB insurance-eligible employee who applies for more insurance than is guarantee-issue, OR
• a PEBB insurance-eligible employee who wants to increase coverage amounts at a later date.

Download the LTD Enrollment/Change Form, then complete and return it to the Benefits Office.

Download the EOI Form if applying for LTD insurance that requires approval from Standard Insurance Company.

Enroll, stop, or change your UWRP contributions at www.fidelity.com/uw, or contact a Fidelity Workplace Planning and Guidance Consultant at 1-800-642-7131 between 5 a.m. -  7 p.m. Pacific Time, Monday - Friday.

Enroll, stop, or change your VIP contributions at www.fidelity.com/uw, or contact a Fidelity Workplace Planning and Guidance Consultant at 1-800-642-7131 between 5 a.m. -  7 p.m. Pacific Time, Monday - Friday.

To download a DCAP Form or document, see ASIFlex's web site.

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

To download a FSA Form or document, see ASIFlex's web site.

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