UW Benefits Forms and Publications
Long Term Disability Insurances

Complete and return this form to the Benefits Office:

• Download the 2013 Enrollment/Change form (PDF)

If you are applying for LTD insurance that requires approval from Standard Insurance Company, complete this form:

• Download the 2013 Evidence of Insurability form (PDF)

• Download the 2013 Long Term Disability Plan Guide (PDF).

Summary of all Public Employee Benefits Board (PEBB) benefits including medical, dental, long term disability, life, etc.

• Download the 2013 PEBB Employee Benefits Enrollment Guide (PDF)

• Employee Self Service (ESS)

Medical Residents & Senior Fellows LTD Application form (PDF) – 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 (PDF) – To continue optional LTD insurance after residency or fellowship is completed. Submit online only.

Dental Student LTD Application form (PDF) – 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 (PDF) – 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."

Physician Assistants LTD Application form (PDF) – This insurance is available only to students enrolled in the MEDEX Northwest Physician Assistant Program.

Dental Students Certificate of Coverage (PDF)

Medical Students Certificate of Coverage (PDF)

Physician Assistants Certificate of Coverage (PDF)

Medical Residents & Senior Fellows Certificate of Coverage (PDF)

Employee Self Service (ESS)