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Unclassified-Transfer - University of Wisconsin System

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					                                    University of Wisconsin System
                         Unclassified Employee Enrollment Deadline Worksheet
                                            Transfers Only

   Date:                                                                     File Copy:      XXX-XX-
   Employee Name:
   Campus Name or UDDS:
   Job Type:                                       Unclassified Academic Staff
   Job Title:
   Person ID:                                                                      Appointment %:
   Appointment Type:                               12 month (A-Basis)
   Annual Base Salary:
   Annual Salary (based on appt %):                $0
   Monthly Salary:                                 $0.00


               Prior service under the Wisconsin Retirement System (WRS):
                                                              State:          12                       plus months
                                                              Local:           0                       months
First day of WRS covered employment at UW:
30 days from first day of WRS covered employment at UW:                   1/30/1900
Date on which 6 months of WRS coverage is completed at UW:                Completed

                                                       If application is received between these
                                                                                                         Coverage will be
              Benefit Plan Name                                           dates:
                                                                                                            effective:
                                                             From                     To
                                                            * With Employer Contribution                Per Transfer Record
       State Group Health Insurance
    Health Insurance Application (ET-2301)                 1/0/1900                 1/30/1900
                                                                                                        You must submit an
                                                                                                       application to maintain
You are required to pay the less than half time rates for your health insurance.                             coverage.

          State Group Life Insurance
Life Insurance Application/Cancellation/Refusal                                                         Per Transfer Record
                  (ET-2304)                                1/0/1900                 1/30/1900           You must submit an
                                                                                                       application to maintain
   Current Value of Each Unit of Coverage:                                                                   coverage.


       Income Continuation Insurance                       * Without Employer Contribution
  Income Continuation Insurance Application                   N/A                      N/A                      N/A
                (ET-2307)

  Monthly Salary for ICI Premium Purposes**                 * With Employer Contribution
                     $0.00                                 1/0/1900              2/1/1900                     2/1/1900



You are eligible for Standard ICI coverage only.

If not previously enrolled, you have a new enrollment opportunity for the Unclassified ICI program. If previously enrolled,
must submit application to maintain coverage.

** To calculate the monthly salary used to determine your ICI premium, round your annual salary up to the nearest $1,000
and divide by 12.
                                                           (OVER)
                                                       If application is received between these
                                                                          dates:                          Coverage will be
               Benefit Plan Name
                                                                                                             effective:
                                                              From                       To
                                                                                                         Per Transfer Record
            VSP Vision Insurance
                                                            1/0/1900                 1/30/1900           You must submit an
        VSP Vision Application (UWS-66)
                                                                                                        application to maintain
                                                                                                              coverage.
 Note: Once enrolled for plan year, must remain covered for entire calendar year.

                                                                                                         Per Transfer Record
                EPIC Benefits+
  Benefits+ Wisconsin State Employees Group
                                                            1/0/1900                 1/30/1900           You must submit an
 Enrollment Form - EPIC Life Insurance Company
                                                                                                        application to maintain
                    (E11444)
                                                                                                              coverage.

              Dental Wisconsin                              1/0/1900                 2/1/1900                  2/1/1900
  Dental Wisconsin Enrollment Form (UWS-64)

 If previously enrolled, must submit application to maintain coverage (coverage effective per transfer record). If Dental
 Wisconsin was not available at previous state agency and/or you carried Anthem Dental Insurance, you have a new
 enrollment opportunity.
 Note: Once enrolled for plan year, must remain covered for entire calendar year.
        Individual & Family Life Insurance                  1/0/1900                 2/1/1900                  2/1/1900
  Individual & Family Group Term Life Insurance
                   (UWS-1301)


       UW Employees, Inc. Life Insurance                    1/0/1900                 2/1/1900                  2/1/1900
        Group Life Insurance Enrollment


                                                                                                         Per Transfer Record
  Employee Reimbursement Account (ERA) -
                                                            1/0/1900                 1/30/1900           You must submit an
         Mid-Year Plan Enrollment
                                                                                                        application to maintain
                                                                                                              coverage.
    WRS Variable Fund Election (ET-2356)
                                                                                                       January 1st following
  Must send directly to Department of Employee              1/0/1900                12/31/XXXX
                                                                                                           submission
                   Trust Funds


Note: You are eligible to enroll in Accidental Death & Dismemberment (AD&D) Life Insurance, the Tax-Sheltered Annuity
(TSA) 403b program, WI Deferred Compensation and Long-Term Care Insurance at any time. You will also be covered
under the mandatory University Insurance Association (UIA) Life Insurance program if you meet the initial eligibility
requirements. UIA coverage will begin either April 1st or October 1st, depending on your employment begin date.

All benefit applications available online at: http://uwservice.wisc.edu/forms.php

It his highly recommended that you submit your applications within 30 days of your employment start date regardless of the
effective date of coverage. By signing this form, I understand the importance of the deadlines provided to me on this form.
Furthermore, I understand that I can only enroll in these programs in the future during an open enrollment period or
through Medical Evidence of Insurability, if applicable, should I miss these enrollment deadlines.
Employee
Signature: __________________________________________________   Date: _______________________________
                                                                                  UWS-204 (12/11)




                                                (OVER)
(OVER)

				
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