UW Benefits Forms and Publications
For Retirees

This page contains a list of forms and publications for retirees. Navigate the right side bar to find forms and publications specific to other areas of interest.

Unless otherwise noted on the form, please send completed documents to the UW Benefits Office, Box 359556. (We cannot accept enrollment forms sent by fax or email attachment.)
If you prefer to hand-deliver documents or send them through U.S. mail, read these directions.
Read the form carefully to see whether additional documentation is required.
Be sure to make copies of documents for your records before submitting them as we cannot make copies for you.
If you cannot find a form or publication on this page or through one of the links shown at right, contact benefits@uw.edu. One of our support team will respond to your request within 2-3 business days.

Forms for Retirees

Retiree Medical & Dental Coverage Election	Download the 2013 Form (PDF).
2013 Medicare Forms	Form A - Retiree Coverage Election Form - Open Enrollment (PDF) Form B - Medicare Supplement Enrollment (PDF) Form C - Medicare Advantage Enrollment (PDF) Form D - Medicare Advantage Disenrollment (PDF)
Group Life Insurance Conversion or Portability	Conversion: Within 60 days of your or your dependents' coverage termination date, you may apply to convert your group term life insurance to individual whole life insurance.To receive information regarding Conversion Rights, check the Conversion Box on page two of the Group Life Portability Application Form. ReliaStar Life Insurance Company will send you a description of the conversion plan, premiums rates, and an application form. Separating or retiring employees may also contact the Benefits Office for information. Portability: To apply for life insurance portability, contact the Benefits Office within 31 days of your or your dependents' coverage termination date.
Re-Employed Retirees	Re-employed retirees: Complete the Retirement Status Form. For re-employed DRS or UWRP retirees: See Statement Concerning Your Employment in a Job Not Covered by Social Security. Departments: Due to newly enacted legislation, the previous "Request for Approval of PERS/TRS Retiree Employment" form is no longer required.
Authorization for Direct Deposit	Authorization for Direct Deposit – For PERS, LEOFF or TRS retirees to use for all retirement benefit payments from DRS.
Electronic Debit Service	Use the Electronic Debit Service form (PDF) to self-pay your monthly premium while enrolled in retiree insurances.
UW Combined Fund Drive (UWCFD)	Your donations make a difference! Use the UWCFD Donation form to support your favorite charities.
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Publications/Resources for Retirees

University of Washington Retiree ID Card	The UW retiree identification card replaces the UW employee card and is required to receive UW retiree privileges. Only one UW retiree card is available per household. Learn how to obtain one.
PEBB Retiree Enrollment Guide	Summary of all Public Employee Benefits Board (PEBB) benefits including medical, dental, long term disability, life, etc. Download the 2013 Guide.
Address Updates	See chart on the Name & Address Change web page.

University of Washington Retiree ID Card

The UW retiree identification card replaces the UW employee card and is required to receive UW retiree privileges. Only one UW retiree card is available per household. Learn how to obtain one.

PEBB Retiree Enrollment Guide

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

Download the 2013 Guide.

Address Updates

See chart on the Name & Address Change web page.

Contact us if you cannot find a form or publication on this page or through one of the links shown at right. To report a web problems, contact benefits@uw.edu.

FORMS & PUBLICATIONS

UW Benefits Forms and Publications For Retirees

This page contains a list of forms and publications for retirees. Navigate the right side bar to find forms and publications specific to other areas of interest.

Forms for Retirees

Publications/Resources for Retirees

UW Benefits Forms and Publications
For Retirees