Get documents about "University of Wisconsin System Non Represented Classified Employee Enrollment Deadlines Worksheet Transfe
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Description
Employee Enrollment Record document sample
Document Sample
University of Wisconsin System
Non-Represented Classified Employee Enrollment Deadlines Worksheet
Transfers Only
Date: File Copy: XXX-XX-
Employee Name:
Campus Name or UDDS:
Job Type: Classified - Permanent (Non-Rep)
Job Title:
Person ID: Appointment %:
Hourly Rate:
Biweekly Rate: $0.00
Annual Salary: $0
Prior service under the Wisconsin Retirement System (WRS):
State: 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 2 months of State WRS coverage is complete: 2/29/1900
Date on which 6 months of WRS coverage is completed at UW: 6/30/1900
If application is received between these
Coverage will be
Benefit Plan Name dates:
effective:
From To
* Without Employer Contribution
State Group Health Insurance
NA NA Per Transfer Record
Heath Insurance Application (ET-2301)
You must submit an
* With Employer Contribution application to maintain
You are required to pay the less than half time 1/0/1900 1/30/1900 coverage
rates for your health insurance.
State Group Life Insurance Per Transfer Record
Life Insurance Application/Cancellation/Refusal
1/0/1900 1/30/1900
(ET-2304) You must submit an
application to maintain
Current Value of Each Unit of Coverage:
coverage
Per Transfer Record
Income Continuation Insurance
You must submit an
Income Continuation Insurance Application
1/0/1900 1/30/1900 application to maintain
(ET-2307)
coverage
Monthly Salary for ICI Premium Purposes**:
You are eligible for Standard ICI coverage only.
$0.00
Per Transfer Record
VSP Vision Insurance You must submit an
1/0/1900 1/30/1900
VSP Vision Application (UWS-66) application to maintain
coverage
Note: Once enrolled for plan year, must remain covered for entire calendar year.
** 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
Coverage will be
Benefit Plan Name dates:
effective:
From To
EPIC Benefits+ 1/0/1900 1/30/1900 Per Transfer Record
Benefits+ Wisconsin State Employees Group
Enrollment Form You must submit an
(E11444-1006) *If Choosing After 2 Months of WRS application to maintain
NA NA 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 Group Term Life Insurance 1/0/1900 2/1/1900 2/1/1900
Individual & Family Group Term Life Insurance
(03-30539)
UW Employees, Inc. Life Insurance 1/0/1900 2/1/1900 2/1/1900
University of Wisconsin Employees Inc Life
Insurance (GA-1314)
Employee Reimbursement Account (ERA) -
1/0/1900 1/30/1900 Per Transfer Record
Mid-Year Plan Enrollment
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.
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-202 (Rev 11/10)
