UW Benefits Forms and Publications
Most Requested Forms

Download the 2012 Enrollment/Change Form (PDF).

Faculty and staff: Submit this form to enroll or make changes to your health insurance coverage during 2012.

• To add family members to your coverage, you must provide valid dependent verification documents that prove their eligibility, along with the Enrollment/Change form.
• Also, to add a qualified domestic partner to your coverage, you will need to provide a Tax Status form (PDF).

Newly-eligible employees must use this form to apply for guarantee issue amounts (amounts not requiring evidence of insurability).*

• 2012 Life & Accidental Death & Dismemberment (AD&D) Insurance Enrollment/Change Form (PDF)

*PEBB placed a “freeze” on all requests from current employees for changes to life insurance coverage until January 31, 2012 except for those experiencing a qualifying life event. Newly-eligible employees still have 60 days from their eligibility date to enroll in the current life insurance program up to the “guaranteed issue” level, the point at which no proof of good health or life insurance company approval is required.

Current enrollees may use this form to remove coverage, apply for basic dependent or accidental death and dismemberment (AD&D) insurance.*

• 2012 Life & Accidental Death & Dismemberment (AD&D) Insurance Enrollment/Change Form (PDF)

*PEBB placed a “freeze” on all requests from current employees for changes to life insurance coverage until January 31, 2012 except for those experiencing a qualifying life event.

Download this form, then complete and return it to the Benefits Office.

Download this form if applying for LTD insurance that requires approval from Standard Insurance Company.

Log into Employee Self Service (ESS) with your NetID to enroll or make changes. Choose the "Retirement & Savings" tab, then the "change" button under the VIP section.

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.