Name: _________________________________________ DOH: _____________ FTE: _____________ Regular / Temporary WHAT TO BRING TO ORIENTATION You are eligible for Full-Time benefits. Please see the Employee Benefit Summary for details. Employee Health Form Background Check and BID Form Federal I-9 (Employment Eligibility Verification) and Appropriate Forms of Identification (Note: Please see page 3 of the I-9 for a list of acceptable form(s) of identification) WT-4 (State Tax Withholding) and W-4 (Federal Tax Withholding) For coordination of benefits, are you currently enrolled on a UWMF benefit plan (health, dental, flex spending, life insurance) through a spouse, Domestic Partner or other family member? Yes ______ No ______ Health Insurance Enrollment Form (Unity application*) – Waiver form if applicable o HMO Traditional Plan – Cannot enroll in a HSA or Combination Flexible Spending Account o HMO High Deductible Health Plan – Cannot enroll in a Health Care Flexible Spending Account Dental Insurance Enrollment Form (Delta application) – Waiver form if applicable Supplemental Life / AD&D Insurance Enrollment Form Life Insurance & LTD Group Enrollment Form Dependent Life Insurance Enrollment Form LTD Pre/Post Tax Option Form Health Care Flexible Spending Account – Cannot be enrolled if in a High Deductible Health Plan Dependent Care Enrollment Form Health Savings Account – Can only elect if enrolled in a High Deductible Health Plan (HDHP) Combination Flexible Spending Account - Can only elect if enrolled in a High Deductible Health Plan Life Lock Identity Theft Protection Retirement Beneficiary Form Please Note: All forms must be completed regardless if you are enrolling or waiving coverage. Please bring the following completed forms with you to your Employee Health Screening! Please bring the following completed forms with you to New Employee Orientation! All forms must be completed regardless if you are enrolling or waiving coverage.
You are eligible for Full-Time benefits. Please see the Employee Benefit Summary for details.
Employee Health Form Background Check and BID Form
Federal I-9 (Employment Eligibility Verification) and Appropriate Forms of Identification (Note: Please see page 3 of the I-9 for a list of acceptable form(s) of identification)
WT-4 (State Tax Withholding) and W-4 (Federal Tax Withholding)
For coordination of benefits, are you currently enrolled on a UWMF benefit plan (health, dental, flex spending, life insurance) through a spouse, Domestic Partner or other family member? Yes ______ No ______
Health Insurance Enrollment Form (Unity application*) – Waiver form if applicable
o HMO Traditional Plan – Cannot enroll in a HSA or Combination Flexible Spending Account
o HMO High Deductible Health Plan – Cannot enroll in a Health Care Flexible Spending Account
Dental Insurance Enrollment Form (Delta application) – Waiver form if applicable Supplemental Life / AD&D Insurance Enrollment Form Life Insurance & LTD Group Enrollment Form Dependent Life Insurance Enrollment Form LTD Pre/Post Tax Option Form Health Care Flexible Spending Account – Cannot be enrolled if in a High Deductible Health Plan
Dependent Care Enrollment Form Health Savings Account – Can only elect if enrolled in a High Deductible Health Plan (HDHP) Combination Flexible Spending Account - Can only elect if enrolled in a High Deductible Health Plan
Life Lock Identity Theft Protection Retirement Beneficiary Form
Please Note: All forms must be completed regardless if you are enrolling or waiving coverage.
Please bring the following completed forms with you to your Employee Health Screening!
Please bring the following completed forms with you to New Employee Orientation!
All forms must be completed regardless if you are enrolling or waiving coverage.
Form W-4 (2017)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.Note: If another person can claim you as a dependent on his or her tax return, you can’t claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).
Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,
• Is blind, or
• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.
The exceptions don’t apply to supplemental wages greater than $1,000,000.Basic instructions. If you aren’t exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.
Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.
Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A
B Enter “1” if: { • You’re single and have only one job; or• You’re married, have only one job, and your spouse doesn’t work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
} B
C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F
(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child. G
H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H
For accuracy, complete all worksheets that apply. {
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Form W-4Department of the Treasury Internal Revenue Service
Employee’s Withholding Allowance Certificate▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
OMB No. 1545-0074
20171 Your first name and middle initial Last name
Home address (number and street or rural route)
City or town, state, and ZIP code
2 Your social security number
3 Single Married Married, but withhold at higher Single rate.
Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ▶
5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $
7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶
8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2017)
Form W-4 (2017) Page 2 Deductions and Adjustments Worksheet
Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.1 Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state
and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce your itemized deductions if your income is over $313,800 and you’re married filing jointly or you’re a qualifying widow(er); $287,650 if you’re head of household; $261,500 if you’re single, not head of household and not a qualifying widow(er); or $156,900 if you’re married filing separately. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . 1 $
2 Enter: { $12,700 if married filing jointly or qualifying widow(er)$9,350 if head of household . . . . . . . . . . .$6,350 if single or married filing separately
} 2 $
3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2017 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
Withholding Allowances for 2017 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2017 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9
10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note: Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 12 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3
Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.
4 Enter the number from line 2 of this worksheet . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two
weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.
WT-4
W-204 (R. 11-04) Wisconsin Department of Revenue
Employee’s Wisconsin Withholding Exemption Certificate/New Hire Reporting
Employee’s SectionEmployee’s Name (last, first, middle initial Social Security Number Date of Birth
Employee’s address (number and street) City State Zip Code
Date of HireSingle Married Married, but withhold at higher Single rate. Note: If married, but legally separated, check the Single box.
FIGURE YOUR TOTAL WITHHOLDING EXEMPTIONS BELOWComplete Lines 1 through 3 only if your Wisconsin exemptions are different than your federal allowances.
1. (a) Exemption for yourself – enter 1 .........................................................................................................
(b) Exemption for your spouse – enter 1 .................................................................................................
(c) Exemption(s) for dependent(s) – you are entitled to claim an exemption for each dependent .......
(d) Total – add lines (a) through (c) ..........................................................................................................
2. Additional amount per pay period you want deducted (if your employer agrees) ....................................
3. I claim complete exemption from withholding (see instructions). Enter “Exempt” ..................................
I CERTIFY that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled. If claiming complete exemption fromwithholding, I certify that I incurred no liability for Wisconsin income tax for last year and that I anticipate that I will incur no liability for Wisconsin income tax for this year.
Signature Date Signed ,
EMPLOYEE INSTRUCTIONS:• WHO MUST FILE:
Every Employee is required to file a completed Form WT-4 with each of his or heremployers unless the Employee claims the same number of withholding exemp-tions for Wisconsin withholding tax purpose as for federal withholding tax purpose.Form WT-4 (or federal Form W-4 if a Form WT-4 is not filed) will be used by youremployer to determine the amount of Wisconsin income tax to be withheld fromyour paychecks. If you have more than one employer, you should claim a smallernumber or no exemptions on each Form WT-4 filed with employers other thanyour principal employer so that the total amount withheld will be closer to youractual income tax liability.
Your employer may also require you to complete this form to report your hiring tothe Department of Workforce Development.
You may file a new Form WT-4 any time you wish to change the amount of with-holding from your paychecks, providing the number of exemptions you claim doesnot exceed the number you are entitled to claim.
• UNDER WITHHOLDING:If sufficient tax is not withheld from your wages, you may incur additional interestcharges under the tax laws. In general, 90% of the net tax shown on your incometax return should be withheld.
• OVER WITHHOLDING:If you are using Form WT-4 to claim the maximum number of exemptions to whichyou are entitled and your withholding exceeds your expected income tax liability,you may use Form WT-4A to minimize the over withholding.
• WHEN TO FILE IF YOUR EXEMPTIONS CHANGE:You must file a new certificate within 10 days if the number of exemptions previouslyclaimed by you DECREASES.
You may file a new certificate at any time if the number of your exemptionsINCREASES.
• HOW TO COMPLETE FORM WT-4Clearly print your full name (last, first, middle initial), address, social securitynumber and date of birth.
Ý• LINE 1:
(a)-(c) Number of exemptions — Do not claim more than the correct number ofexemptions. If you expect to owe more income tax for the year than will be with-held if you claim every exemption to which you are entitled, you may increase yourwithholding by claiming a smaller number of exemptions on lines 1(a)-(c) or youmay enter into an agreement with your employer to have additional amountswithheld (see instruction for line 2).(c) Dependents — Those persons who qualify as your dependents for federalincome tax purposes may also be claimed as dependents for Wisconsin purposes.The term “dependents” does not include you or your spouse. Indicate the numberof dependents that you are claiming in the space provided.
• LINE 2:Additional withholding — If you have claimed “zero” exemptions on line 1, but stillexpect to have a balance due on your tax return for the year, you may wish torequest your employer to withhold an additional amount of tax for each pay period.If your employer agrees to this additional withholding, enter the additional amountyou want deducted from each of your paychecks on line 2.
• LINE 3:Exemption from withholding — You may claim exemption from withholding ofWisconsin income tax if you had no liability for income tax for last year, and youanticipate that you will incur no liability for income tax for this year. You may notclaim exemption if your return shows tax liability before the allowance of any creditfor income tax withheld. If you are exempt, your employer will not withhold Wis-consin income tax from your wages.You must revoke this exemption (1) within 10 days from the time you anticipateyou will incur income tax liability for the year or (2) on or before December 1 if youanticipate you will incur Wisconsin income tax liabilities for the next year. If youwant to stop or are required to revoke this exemption, you must file a new FormWT-4 with your employer showing the number of withholding exemption you areentitled to claim. This certificate for exemption from withholding will expire on April30 of next year unless a new Form WT-4 is filed before that date.
Employer’s SectionEmployer’s Name Federal Employer ID Number
Employer’s payroll address (number and street) City State Zip Code
EMPLOYER INSTRUCTIONS for Department of Revenue:• If you do not have a Federal Employer Identification Number (FEIN), contact the
Internal Revenue Service to obtain a FEIN.
• If the Employee has claimed more than 10 exemptions OR has claimed completeexemption from withholding and earns more than $200.00 a week or is believedto have claimed more exemptions than he or she is entitled to, mail a copy of thiscertificate to: Wisconsin Department of Revenue, Audit Bureau, P.O. Box 8906,Madison, WI 53708 or fax (608)-267-0834.
• Keep a copy of this certificate with your records. If you have questions about theDepartment of Revenue requirements, call (608) 266-8646 or (608) 266-2776.
EMPLOYER INSTRUCTIONS for New Hire Reporting:• This report contains the required information for reporting New Hire to Wisconsin.
Mail the original form to the Department of Workforce Development, NewHire Reporting, PO Box 14431, Madison, WI 53708-0431 or fax toll free to1-800-277-8075.
• If you are reporting New Hires electronically, you do not need to forward a copy ofthis report to Department of Workforce Development.
• If you have questions about New Hire requirements, call toll free (888) 300-HIRE(888-300-4473).
smmeyer
University of Wisconsin Medical Foundation, Inc.
smmeyer
39-1824445
smmeyer
7974 UW Health Court
smmeyer
Middleton
smmeyer
WI
smmeyer
53562
USCIS Form I-9
OMB No. 1615-0047 Expires 08/31/2019
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 11/14/2016 N Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)
Address (Street Number and Name) Apt. Number City or Town State ZIP Code
Date of Birth (mm/dd/yyyy) U.S. Social Security Number
- -
Employee's E-mail Address Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until (See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1 Do Not Write In This Space
Signature of Employee Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)
Last Name (Family Name) First Name (Given Name)
Address (Street Number and Name) City or Town State ZIP Code
Employer Completes Next Page
Form I-9 11/14/2016 N Page 2 of 3
USCIS Form I-9
OMB No. 1615-0047 Expires 08/31/2019
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1 Citizenship/Immigration Status
List AIdentity and Employment Authorization Identity Employment Authorization
OR List B AND List C
Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)
Signature of Employer or Authorized Representative Today's Date(mm/dd/yyyy) Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial
B. Date of Rehire (if applicable)Date (mm/dd/yyyy)
Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED
Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.
3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
4. Employment Authorization Document that contains a photograph (Form I-766)
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:
Documents that Establish Both Identity and
Employment Authorization
6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;
and(2) An endorsement of the alien's
nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are unable to present a document
listed above:
1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
9. Driver's license issued by a Canadian government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish Identity
LIST B
OR AND
LIST C
8. Employment authorization document issued by the Department of Homeland Security
1. A Social Security Account Number card, unless the card includes one of the following restrictions:
2. Certification of Birth Abroad issued by the Department of State (Form FS-545)
3. Certification of Report of Birth issued by the Department of State (Form DS-1350)
4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
5. Native American tribal document
7. Identification Card for Use of Resident Citizen in the United States (Form I-179)
Documents that Establish Employment Authorization
6. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3Form I-9 11/14/2016 N
Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
2017 Domestic Partnership Affidavit
For Health Insurance, Dental Insurance, Survivor Income Benefit for Long-Term Disability, Dependent Life Insurance, and/or Supplemental Life Insurance
We, , and Name of Employee Name of Domestic Partner
Certify that:
1. The effective date of this Domestic Partnership is and that this Domestic Partnership has been in existence for a period of twelve (12) consecutive months prior to our signature of this Affidavit.
2. We share the common necessities of life.
3. We are not legally married to anyone else.
4. We are at least eighteen (18) years of age or older.
5. We are not related by blood closer than would bar marriage in the state of our residence and are mentallycompetent to consent to contract.
6. We are each other’s sole Domestic Partner and intend to remain so indefinitely and are responsible for our commonwelfare.
7. Domestic partners must have at least three of the following: Joint ownership or common leasehold in a residence; Joint ownership of motor vehicle; Joint ownership of a checking account or credit account; Designation of the domestic partner as beneficiary for the employee’s life insurance or retirement benefits Shared household expenses.
8. Neither the domestic partner nor the UWMF employee has entered into the relationship for the purpose of obtaininginsurance coverage.
9. We understand that any person, employer, or company who suffers any loss because of false statements containedin a “Domestic Partnership Affidavit” may bring a civil action against us to recover the losses, including reasonableattorney fees.
10. We understand the information in this affidavit will be used by the Employer for the sole purpose of determining oureligibility for Domestic Partnership benefits. We further understand that this information will be held confidential andwill be subject to disclosure only upon our expressed written authorization or pursuant to a court order.
11. We affirm, under penalty of perjury, that the statements in this Affidavit are true and correct to the best of ourknowledge.
12. (If applicable) I am part of a same sex marriage and was married in the State of _______________________which recognizes same sex marriage.
Signature of Employee Signature of Domestic Partner
Employee’s Social Security Number Domestic Partner’s SSN
Employee’s Date of Birth Domestic Partner’s Date of Birth
Date Date
New Hire
Employees: Return completed form via inter-departmental mail: 2409-HR or fax: (608) 263-5778
Declaration of Tax Status Form Employees: Return completed form via inter-departmental mail: 2409-HR or fax: (608) 263-5778
UWMF Human Resources to Complete: PS Entry Completed By: ___________________ Date of Entry: ______________
This form is only completed if you are enrolling your Domestic Partner (DP), Qualifying Child (with a disability) or Qualifying Relative in medical and/or dental coverage. The Affordable Care Act requires group health plans to provide dependent medical coverage of children up to the age of 26. UWMF also offers a dental plan which covers unmarried dependents up to the age of 25. This form does not get completed in these cases.
The University of Wisconsin Medical Foundation (UWMF) offers health and dental coverage to qualified domestic partners, qualified adult child(ren) or relative(s). Qualified child(ren) or relatives are typically an adult the employee has guardianship over due to permanent and total disability, including children over the age of 25. Please see Human Resources if this situation may apply to you. To ensure proper taxation of the cost of health and dental insurance applicable to the Domestic Partner or qualified adult, UWMF must know the Federal and/or State tax status of these individuals. The tax status of these family members doesn’t affect their eligibility for coverage, but does affect whether you (the subscriber) will be taxed on the value of their health coverage.
Section 1: Determining Dependent’s Federal and/or State Tax Status
Complete and return this form to declare whether your Domestic Partner or Other Qualifying Relative qualifies as an Internal Revenue Code (IRC) Section 152 dependent. Please apply the following tests to each dependent to determine their Federal and/or State Tax Status. Note that the individual(s) has to pass Test A OR Test B in order to qualify as an IRC Section 152 dependent. We recommend that you consult your tax advisor if you have questions about your specific circumstances. Note: If applicable, domestic partner coverage is subject to State and Federal Taxes.
TEST A: Qualifying Child TEST B: Qualifying Relative
IRC requires a qualifying child meet all of the following tests to qualify as your tax dependent: 1. The child must be your son, daughter, stepchild, foster child, brother, sister, half-sibling, step-sibling, or a descendant of any of them.
2. The child must be (a) under age 19 at the end of the year and younger than you (or your spouse, if filing jointly), (b) under age 24at the end of the year, a FT student and younger than you (or your spouse, if filing jointly), or (c) any age if permanently and totally disabled. 3. The child must have lived with you for more than half the year (exceptions exist).4. The child must not have provided more than half of his or her own support for the year. 5. The child is not filing a joint return for the year (unless that return is filed only as a claim for refund).6. If the child meets the rules to be a qualifying child of more than one person, only one person can actually treat the child as aqualifying child. 7. Special rule for disabled: In the case of an individual who is permanently and totally disabled, as defined in section 22 (e)(3) which states an individual is permanently and totally disabled if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. An individual shall not be considered to be permanently and totally disabled unless he furnishes proof of the existence thereof in such form and manner, and at such times, as may be required.
OR
The IRC requires that a qualifying relative meet all of the following tests to qualify as your tax dependent:
1. The person cannot be your qualifying child or the qualifying child of any other taxpayer.2. The person either (a) must be related to you in one of the ways listed under ‘Relatives
who do not live with you’, or (b) must live with you all year as a member of yourhousehold (and your relationship must not violate the law).
3. The person’s gross income for the year must be less than $3,700 (there is an exception if the person is disabled and has income from a sheltered workshop.
4. You must provide more than half of the person’s total support for the year (There areexceptions for multiple support agreements, children of divorced or separated parents or parents who live apart, and kidnapped children).
Additional information can be found at www.irs.gov/publications/p17/ch03.html
Section 2: Dependent Tax Status Information With the exception of your spouse, list the individuals over the age of 18 that you wish to enroll as a Qualifying Child or Qualifying Relative (including Domestic Partner, and indicate whether they qualify as your Federal and/or State tax dependent.
Qualifying Child or Relative Name Date of Birth SSN Relationship to Employee Federal and/or State Tax Status I am part of a same sex marriage and was married in a state that recognizes same sex marriage.
Yes, this person qualifies as my IRC Section 152 dependent No, this person does not qualify as my IRC Section 152
dependent. Federal &/or State taxes will be applied to the cost of their coverage.
I am part of a same sex marriage and was married in a state that recognizes same sex marriage. Yes, this person qualifies as my IRC Section 152 dependent
No, this person does not qualify as my IRC Section 152 dependent. Federal &/or State taxes will be applied to the cost of their coverage.
Section 3: Signature - Required
I declare that the information I have provided is true, complete and correct. If it is not, or if I do not update this information within the timeliness in UWMF rules, I must repay any premiums that have been paid on my behalf. I understand that knowingly providing false, incomplete, or misleading information to UWMF for the purpose of defrauding the company will result in appropriate discipline. I understand that:
This declaration of responsibility may have legal implications under Federal and/or State law.
A civil action may be brought against me for any losses, including reasonable attorney’s fees, if I have made a false statement in this declaration.
I must notify UWMF human resources if there is a change in my domestic partnership or dependent status no later than 60 days after the change. Any change in my family status may directly impact the calculation of my taxable income.
UWMF’s Privacy Notice: We will keep your information private as allowed by law.
Employee’s printed name ____________________________________________________________ Employee ID_________________
Waiver of Group Health and/or Dental Insurance Coverage
I have been given an opportunity to apply for group insurance as offered by the policyholder, and after careful consideration have decided not to take advantage of this offer. I certify that this wavier was signed voluntarily and in no way did anyone coerce or induce me to waive coverage.
Should I desire to apply for health and/or dental insurance coverage in the future, I understand my dependents and I may be subject to a waiting period, unless I am applying due to loss of coverage or a qualifying event. I further understand that if I experience a loss of coverage, I may be eligible to enroll my dependents and myself provided that I do so within 30 days after my other coverage ends. If I experience a qualifying event (i.e. new dependent as a result of marriage, birth, or adoption), I may be able to enroll my dependents, and myself provided I request enrollment within 30 days of the date of the event. Failure to request coverage within the required time frame, will result in a delay of coverage for my dependents and myself.
____________________________________ _____________________ Employee Name (Please Print) Social Security Number
____________________________________ _____________________ Employee Signature Date
KBG354
Line
KBG354
Rectangle
UH00674 (rev 09 16)
Name of Employer Group: Hours Worked Date Employed:
Per Week: _____/_____/_____
Employment Status: � Active � Retired � LOA � COBRA / Continuation Effective Date ______/_____/______ and Term Date: ______/_____/______
Plan Requested: � Traditional HMO _____________________________ � HMO HDHP_____________________________
Group Number: Group Number:
Type of Coverage: � Employee � Employee and Spouse � Employee and Child(ren � Family
Reason for Enrollment: (check appropriate box) Requested Effective Date of Coverage: _____/_____/_____
� New Hire � Marriage � Birth, adoption / placement for adoption
� Loss of other coverage � Open enrollment � Add / delete dependents� Name change / address change / PCP change � Part-time to full-time employment � Rehire (date): _____/_____/_____
(date of change: _____/_____/_____)� Return from layoff (date): _____/_____/_____� Late applicant
� Transfer to retiree segment� Transfer to disability segment
Subscriber #__________________________________________________________ Effective Date of Coverage____________________ Termination Date__________________
Names of those covered under policy:
Employee’s Last Name First Name MI
Social Security Number or Tax ID Number
Street Address Apt. # City State Zip Code County
Mailing Address (if different) City State Zip Code County
Date of Birth Gender Marital Status � Single � Divorced Primary Language Spoken
_____/_____/______ � M � F � Married____________________________________ � English � Spanish � Other_________________
Home Phone # ( ) Work Phone # ( )
Cell Phone # ( ) Applicant’s E-Mail Address:
*Primary Care Physician (PCP) and Clinic: *If you want Unity to assign you to a Clinic or a PCP, indicate “ASSIGN” Current Patient?
� Yes � No
EMPLOYEE INFORMATION (Please do not use abbreviations or nicknames on this application)
FOR EMPLOYER USE – EMPLOYMENT INFORMATION:
(provide date when marriage occurred)
840 Carolina Street • Sauk City, WI 53583-1374 (800) 362-3309 • Fax (608) 643-2564unityhealth.com
Employee ApplicationPlease Complete Entire Form in BLACK INK.
(SSN / TIN is required for IRS tax reporting regarding your health plan.) ____ ____ ____ – ____ ____ – ____ ____ ____ ____
Return completed forms to Human Resources via interdepartmental mail: Mail code: 2409-HR or fax: (608) 263-5778
New Hire
UH00674 (rev 09 16)
Dependent’s Last Name First Name MI
Social Security Number or Tax ID Number
Street Address (if different than employee) Apt. # City State Zip Code County
Mailing Address (if different than employee) City State Zip Code County
Relationship Date of Birth _____/_____/______
Gender � M � F
*Primary Care Physician (PCP) and Clinic: *If you want Unity to assign you to a Clinic or a PCP, indicate “ASSIGN” Current Patient?
� Yes � No
DEPENDENT INFORMATION – Please list all other members to be covered:
(SSN / TIN is required for IRS tax reporting regarding your health plan.) ____ ____ ____ – ____ ____ – ____ ____ ____ ____
Dependent’s Last Name First Name MI
Social Security Number or Tax ID Number
Street Address (if different than employee) Apt. # City State Zip Code County
Mailing Address (if different than employee) City State Zip Code County
Relationship Date of Birth _____/_____/______
Gender � M � F
*Primary Care Physician (PCP) and Clinic: *If you want Unity to assign you to a Clinic or a PCP, indicate “ASSIGN” Current Patient?
� Yes � No
DEPENDENT INFORMATION – Please list all other members to be covered:
(SSN / TIN is required for IRS tax reporting regarding your health plan.) ____ ____ ____ – ____ ____ – ____ ____ ____ ____
Dependent’s Last Name First Name MI
Social Security Number or Tax ID Number
Street Address (if different than employee) Apt. # City State Zip Code County
Mailing Address (if different than employee) City State Zip Code County
Relationship Date of Birth _____/_____/______
Gender � M � F
*Primary Care Physician (PCP) and Clinic: *If you want Unity to assign you to a Clinic or a PCP, indicate “ASSIGN” Current Patient?
� Yes � No
DEPENDENT INFORMATION – Please list all other members to be covered:
(SSN / TIN is required for IRS tax reporting regarding your health plan.) ____ ____ ____ – ____ ____ – ____ ____ ____ ____
Dependent’s Last Name First Name MI
Social Security Number or Tax ID Number
Street Address (if different than employee) Apt. # City State Zip Code County
Mailing Address (if different than employee) City State Zip Code County
Relationship Date of Birth _____/_____/______
Gender � M � F
*Primary Care Physician (PCP) and Clinic: *If you want Unity to assign you to a Clinic or a PCP, indicate “ASSIGN” Current Patient?
� Yes � No
DEPENDENT INFORMATION – Please list all other members to be covered:
(SSN / TIN is required for IRS tax reporting regarding your health plan.) ____ ____ ____ – ____ ____ – ____ ____ ____ ____
OTHER INSURANCE INFORMATION:
Will you or any of your dependents continue to have other insurance after the Unity Health Insurance effective date of this policy? If Yes, complete –
Names of those covered under policy Employer
Insurance Company Subscriber # Group #
Effective Date of Coverage Insurance Company Phone #
Termination Date
Are you or your spouse or child(ren) covered by Medicare (Parts A, B, C, or D)? � Yes � NoIf yes, please list name(s):
Reason for Medicare: � Age 65 � Disability � End Stage Renal Disease � Disability and ESRD
Part A Effective Date: _____________ Part B Effective Date: ______________ Part C Effective Date: ______________ Part D Effective Date: ______________
Are you or any dependents listed above involved in a Workers Compensation case? � Yes � NoIf Yes, indicate who is involved and start date / accident date:
Workers Compensation Condition:
Insurance Company Name:
Insurance Company Address (where claim is sent):
Insurance Company Phone Group # Effective Date: Term Date (if applicable):
UH00674 (rev 09 16)
I hereby elect not to apply for group health plan coverage. I hereby waive group health plan coverage for: � Myself � Spouse � Children or other eligible dependents Reason for waiving coverage –
� I / we will be covered under another health benefit plan that is not sponsored by my employer.
Name of Insurance Co.: _________________________________________________________________________________________________
� I would have to pay more than 10 percent of my annualized gross income towards health insurance
� Other reason for waiving:_________________________________________________________________________________________________
I certify that I have been given the opportunity to apply for the Unity group health benefit plan coverage for which I am eligible. I decline to enrollfor such coverage as indicated above, on behalf of the persons listed above. I understand that I may be able to obtain coverage at a later timefor reasons listed in the Notice of Special Enrollment Rights. If circumstances in the Notice of Special Enrollment Rights do not apply then meand / or the persons listed above may be considered Late Applicants subject to either a 12 month delayed effective date, or, if my employer hasan Open Enrollment Period, may be able to apply for coverage at Open Enrollment.
I certify that the information above is, to the best of my knowledge and ability, complete and true.
I acknowledge that I have read and completed the entire Application. If I received assistance in reading or completing this Application, I have identifiedthe person(s) who assisted me.
I agree that the answers are, to the best of my knowledge and ability, complete and true. I understand that my answers, together with any supplementsor additional pages, are the basis for the certificate or policy that is issued. I agree that no insurance will be effective until the date specified by theinsurance company on the certificate or policy. I understand that any material misstatement or omission relied upon by the insurer may result in denialof claim and / or rescission of coverage. I further understand that this contract can be voided if within the first 24 months from the date of the policy orcertificate it is determined that I or a dependent made an intentional misrepresentation in the application.
I understand that it may be a crime to submit an application or file a claim based on a false or deceptive statement. I further understand it may be acrime to submit an application that is intended to mislead an insurer or conceal significant information about the applicant.
I understand that I may request a copy of this Application and the notice of the company’s privacy practices. I agree that a photocopy is as valid as anoriginal. A legible facsimile or electronic signature shall have the same force as the original.
I understand that enrollment and / or eligibility for benefits may be conditioned upon my willingness to provide written authorization permitting Unity toobtain medical records from health care providers who have treated me, my spouse or any dependents applying for coverage under this application. Ifmedical records are needed, Unity will provide me with an authorization form.
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage,you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stopscontributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ othercoverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth,adoption or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days afterthe marriage, birth, adoption or placement for adoption.
UH00674 (rev 09 16)
Delta Dental of Wisconsin
Enrollment/Change/Waiver Form - Dental PLEASE NOTE THAT COMPLETING THIS FORM DOES NOT GUARANTEE COVERAGE.
EMPLOYER USE ONLY
GROUP NUMBER ______________ ______________ ______________ ______________ EFFECTIVE DATE _________________________
Acceptance of Coverage
I accept the insurance provided by my employer’s group insurance plan. I authorize deductions from my earnings for the required contributions toward the cost of insurance. (This authorization applies only if employee contributions are required.) I understand that by accepting insurance, I am required to remain enrolled as a covered employee and cannot make an elective change in the coverage selected until the next open enrollment period, if there is one provided for in the Master Agreement to Provide Dental Benefits.
Waiver of Coverage
I understand that if I decide not to apply for coverage, or if I apply only for single coverage even though I am eligible for family coverage, any subsequent application will be subject to the applicable terms and conditions of the Master Agreement to Provide Dental Benefits, which may require additional limitations and waiting periods. I also understand that Delta Dental of Wisconsin, Inc. reserves the right to reject such an application.
F708A-1411
COMPLETE THIS SECTION IF YOU ARE ACCEPTING, CHANGING, OR TERMINATING COVERAGE EMPLOYEE LAST NAME FIRST M.I. SSN OR EMPLOYER-ASSIGNED ID DATE OF BIRTH (M/D/Y) SEX
HOME ADDRESS - STREET CITY STATE ZIP
EMPLOYER NAME EMPLOYER LOCATION CITY STATE DATE OF HIRE (M/D/Y)
LIST ALL ELIGIBLE FAMILY MEMBERS TO BE COVERED RELATIONSHIP
SPOUSE LAST NAME (IF DIFFERENT) FIRST M.I. SON DAU. DATE OF BIRTH (M/D/Y)
NEW ENROLLEE REHIRE (Date: _____________________________)
Group Transfer (From _____________To _________________) _______________
COBRA Application _______________
Date Occurred
ACCEPT COVERAGE
Signature is Required Date
X
REASON FOR SUBMITTING THIS FORM COVERAGE TYPE
WHAT TYPE OF COVERAGE ARE YOU APPLYING FOR?
Employee Only Employee & Spouse
Employee & Child(ren) Entire Family
YOUR MARITAL STATUS Single Married
If you are not accepting coverage for your spouse or dependents, are they covered by another dental plan? Yes No
COMPLETE THIS SECTION ONLY IF YOU ARE WAIVING COVERAGE
EMPLOYEE LAST NAME FIRST M.I. SSN OR EMPLOYER-ASSIGNED ID PLEASE CHECK ONE:
I have coverage through my spouse
I have other dental coverage
I do not have other dental coverageEMPLOYER NAME EMPLOYER LOCATION CITY STATE
Signature is Required Date
XWAIVE COVERAGE
F M
New Hire
Return completed forms via interdepartmental mail: mail code 2409-HR or fax: (608) 263-5778.
Updated 09.25.14
Name: Social Security Number:
Salary: Date of Birth:
Date of Hire: Effective Date:
Hours Worked/FTE Occupation
The following costs should be calculated based on your age as of January 1 of the current year.
Supplemental Life/AD&D Insurance - Employee You can purchase Supplemental Life/AD&D Insurance in increments of $10,000. The maximum amount you can purchase cannot be more than $750,000. When you are newly eligible for this coverage the guaranteed issue amount is $250,000. If you elect an amount that exceeds the guaranteed issue amount of $250,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective.
Use the rate chart and calculation line below to determine your semi-monthly cost for this coverage. *
Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
I elect to enroll in the Supplemental Life/AD&D plan at the semi-monthly cost below. *
÷ $1,000 = x X 12 ÷ 24 = $
Elected Benefit Amount Rate Above Your Semi-Monthly Cost*
I elect to decline the Supplemental Life/AD&D plan.
* Your cost may change if your age category changes as January 1.
*Note: Benefit reductions begin at age 65. Please see your benefits administrator for further information.
Supplemental Life Insurance – Spouse/Domestic Partner If you elect Supplemental Life Insurance for yourself, you may elect Spouse Supplemental Life Insurance in increments of $10,000. The maximum amount you can purchase cannot be more than the lesser of $250,000 or 50% of your Supplemental Life Insurance. When your spouse or DP is newly eligible for this coverage, the guaranteed issue amount is $30,000. If you elect an amount that exceeds the guaranteed issue amount of $30,000, your spouse or DP will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. Supplemental Spouse or DP rates and premiums are based on the employee’s age, not the Spouse’s or DP’s age.
Use the rate chart and calculation line below to determine your semi-monthly cost for this coverage. *
Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
If you purchase Supplemental Life Insurance for yourself, you may purchase Child(ren) Supplemental Life Insurance for your Dependent Child(ren) between the ages of 2 weeks and 19* years and unmarried (25* years if a full time student and unmarried) in the amount of $10,000. *If your child is no longer eligible for this benefit it is your responsibility to notify HR they will assist you in making this change.
I elect to enroll my dependent child(ren) in the Supplemental Life plan for $10,000 at the semi-monthly cost below.
x .25 = $
# of Covered Children Cost Per Child Above Your Semi-Monthly Cost
I elect to decline to purchase the Supplemental Life plan for my dependent child(ren).
First Name Last Name Gender Date of Birth
Beneficiary Designation You must select your beneficiary – the person (or more than one person) or legal entity (or more than one entity) who receives a benefit payment if you die while covered by the plans. Please make sure that you also name a contingent beneficiary – who would receive your benefit if your primary beneficiary dies first.
Please make sure your beneficiary designation is clear so that there will be no question as to your meaning. If you name more than one primary or contingent beneficiary, show the percentage of your benefit to be paid to each beneficiary. Please provide all of the information requested below. If your beneficiary is not related either by blood or by marriage, insert the words, “Not Related” as their stated relationship. If you need assistance, contact your benefits administrator or your own legal advisor.
Full Name Address Social
Security # Relationship
Date of Birth
Percent-age
Primary Beneficiary
Contingent Beneficiary
The beneficiary for insurance on the lives of your spouse and children will automatically be you, if surviving. Otherwise, the beneficiary will be the estate of the spouse and children, subject to policy provisions. A beneficiary for employee Life Insurance may be changed upon written request.
NOTE: Spousal Consent For Community Property States Only: If you live in a community property state – Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin – you must complete a Supplemental Life Insurance Plan Spousal Consent Form, which allows your spouse to waive his or her rights to any community property interest in the benefit.
Employee Confirmation I acknowledge that I have been given the opportunity to enroll in University of Wisconsin Medical Foundation’s Group Supplemental Life/AD&D plans. I understand and agree that if I decline coverage now, but later decide to enroll, I will be required to provide evidence of insurability that is satisfactory to The Hartford and be approved for such coverage before it becomes effective. I understand my request for coverage may be denied by The Hartford.
I understand and agree that insurance will go into effect and remain in effect only in accordance with the provisions, terms and conditions of the insurance policy. I understand and agree that only the insurance policy issued to the policyholder (your employer) can fully describe the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the enrollment form and the insurance policy, I agree to be bound by the insurance policy.
If I have life insurance coverage with The Hartford, I understand and agree that my life insurance benefit is reduced at a specified age stated in the policy.
I authorize my employer to make the appropriate payroll deductions from my earnings.
I understand that no insurance will be valid or in force if I am not eligible in accordance with the terms of the group policy as issued to my employer.
Signature: Date:
Supplemental Life Insurance Plan
Spousal Consent Form
I, the undersigned spouse of __________________________________________________________________named in the foregoing (Participant/Employee Name – please print)
“Designation of Beneficiary”, hereby certify that I have read the Designation of Beneficiary and fully understand the property subject to the designation is my spouse’s benefit under the Plan, in which I possess a beneficial interest, provided I survive my spouse. Being fully satisfied with the provisions of the designation, I hereby consent to and accept the beneficiary designation, without regard to whether I survive or predecease my spouse. This consent is irrevocable unless my spouse changes the designation. If my spouse changes the designated (choose either a or b)
_____ (a) I understand I must sign a similar consent to agree with any changes in the designation, or my consent is no longer effective; or
_____ (b) I waive my right to withhold my consent to a change in designation. I understand that I do have the right to limit my consent to the specific beneficiary designated on the life insurance or request for change form by checking line (a).
I have executed this consent this _________ day of ________________________________, 20_______.
_____________________________________________Signature of spouse of participant
Witness by Plan Representative
Signature of spouse for consent witnessed this ______ day of _________________________, 20______.
Before me, as the undersigned Notary Public, personally appeared _________________________________ who executed the above Spousal Consent as a free and voluntary act.
In witness whereof, I have signed my name and affixed by official notarial seal this _______ day of _______________________, 20_______.
_____________________________________________(SEAL) Notary Public
My commission expires:__________________________
Note: If you are married and you do not name your spouse as your only primary beneficiary, your spouse’s signature must be notarized on this page. Return completed form to: UW Health Human Resources - Benefits
Mail code: 2409-HRFax: (608) 263-5778
COMPLETE THIS FORM ONLY IF YOU DO NOT LIST YOUR SPOUSE AS PRIMARY BENEFICIARY.
GROUP LIFE AND LTD ENROLLMENT/CHANGE FORM EMPLOYER INFORMATION EMPLOYER’S FULL LEGAL NAME
UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
GROUP POLICY#
036143
BILL UNIT LOSS UNIT
ENROLLMENT INFORMATION
PLEASE CHECK ONE OF THE FOLLOWING:
INITIAL ENROLLMENT
CHANGE TO EXISTING ENROLLMENT
NAME / ADDRESS CHANGE (FORMER NAME ) BENEFICIARY CHANGE ( LIFE/AD&D OR SUPP LIFE)
COVERAGE CHANGE (ADD DELETE EFFECTIVE DATE )
FAMILY STATUS CHANGE (TYPE EFFECTIVE DATE )
EMPLOYEE INFORMATION EMPLOYEE’S NAME (LAST, FIRST, MIDDLE INITIAL) DATE OF BIRTH GENDER MARITAL STATUS SOCIAL SECURITY NUMBER
EMPLOYEE’S HOME ADDRESS CITY / STATE MARRIAGE DATE ZIP
SPECIALTY/OCCUPATION EARNINGS (AS DEFINED BY THE POLICY) YR # HOURS WORKED PER WEEK DATE OF HIRE
BENEFICIARY INFORMATION PRIMARY LIFE BENEFICIARY NAME RELATIONSHIP DATE OF BIRTH SOCIAL SECURTIY NUMBER % OF BENEFIT
PRIMARY LIFE BENEFICIARY NAME RELATIONSHIP DATE OF BIRTH SOCIAL SECURTIY NUMBER % OF BENEFIT
CONTINGENT LIFE BENEFICIARY NAME RELATIONSHIP DATE OF BIRTH SOCIAL SECURTIY NUMBER % OF BENEFIT
Note: If additional space is needed, use back of form. Your beneficiary designation can be changed at any time. If you are married and/or divorced and reside in a community property state, you should consult with your legal counsel prior to changing your beneficiary. The designation takes effect as of the date the completed form is received and accepted by The Hartford.
APPLICABLE BENEFIT ELECTIONS Please make your benefit elections by checking the appropriate box. Contact your employer for plan details.
LONG TERM DISABILITY YES NO SUPPLEMENTAL LIFE AND AD&D* YES—$ NO
LIFE AND AD&D* YES NO SUPPLEMENTAL SPOUSE LIFE* YES—$ NO
SPOUSE LIFE YES NO SUPPLEMENTAL CHILD LIFE YES—$ NO
DEPENDENT LIFE YES NO If applicable, the accidental death benefit (AD&D) will equal the face amount of the life insurance elected.
SPOUSE INFORMATION SPOUSE’S NAME SPOUSE’S GENDER SPOUSE’S SOCIAL SECURITY NUMBER SPOUSE’S DATE OF BIRTH
APPLICATION FOR COVERAGE I apply for the group insurance coverage checked above provided under my employer plan. I authorize deductions from my wages to cover my contribution, if required. If I have declined any contributory coverages for which I am eligible above, I understand that to later enroll for these coverages satisfactory medical evidence of insurability will be required and the insurance carrier will have the right to refuse my request. Any person who knowingly, and with the intent to defraud or deceive any insurance company, submits an insurance application containing any false, incomplete or misleading information may be subject to civil or criminal penalties, depending upon state law.
EMPLOYEE SIGNATURE DATE
New Hire
COMPLETE THIS FORM ONLY IF YOU DO NOT LIST YOUR SPOUSE AS PRIMARY BENEFICIARY.
Life Insurance Spousal Consent Form
I, the undersigned spouse of __________________________________________________________________named in the foregoing (Participant/Employee Name – please print)
“Designation of Beneficiary”, hereby certify that I have read the Designation of Beneficiary and fully understand the property subject to the designation is my spouse’s benefit under the Plan, in which I possess a beneficial interest, provided I survive my spouse. Being fully satisfied with the provisions of the designation, I hereby consent to and accept the beneficiary designation, without regard to whether I survive or predecease my spouse. This consent is irrevocable unless my spouse changes the designation. If my spouse changes the designated (choose either a or b)
_____ (a) I understand I must sign a similar consent to agree with any changes in the designation, or my consent is no longer effective; or
_____ (b) I waive my right to withhold my consent to a change in designation. I understand that I do have the right to limit my consent to the specific beneficiary designated on the life insurance or request for change form by checking line (a).
I have executed this consent this _________ day of ________________________________, 20_______.
_____________________________________________Signature of spouse of participant
Witness by Plan Representative
Signature of spouse for consent witnessed this ______ day of _________________________, 20______.
Before me, as the undersigned Notary Public, personally appeared _________________________________ who executed the above Spousal Consent as a free and voluntary act.
In witness whereof, I have signed my name and affixed by official notarial seal this _______ day of _______________________, 20_______.
_____________________________________________(SEAL) Notary Public
My commission expires:__________________________
Note: If you are married and you do not name your spouse as your only primary beneficiary, your spouse’s signature must be notarized on this page. Return completed form to: UW Health Human Resources - Benefits
Mail Code: 2409-HRFax: (608) 263-5778
Dependent Life Insurance HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
Name Soc Sec No Title Date of Birth Date of Hire Effective Date
Basic Life Insurance – Spouse and Child(ren)
You may elect life coverage for your Spouse/Domestic Partner and Child(ren). If you elect this coverage, your Spouse/Domestic Partner will be covered for $10,000 and each child for $5,000. Children under the age of 6 months are covered for $100. Child, for the purpose of this coverage, must be unmarried and under age 19 or under age 25, if a full time student. If both you and your spouse are employees of the University of Wisconsin Medical Foundation, only one of you may elect this coverage.
I elect to enroll my Spouse/Domestic Partner and/or Child(ren) in the Dependent Life plan at a monthly cost of $0.93
I elect to decline the Dependent Life plan for my Spouse/Domestic Partner and/or Child(ren)
I elect to decline this benefit, as I do not have a Spouse/Domestic Partner and/or Child(ren)
Employee Confirmation
I have been given the opportunity to enroll in Basic Life Dependent Coverage for my eligible dependents. I understand that the beneficiary for this coverage is myself.
__________________________________________ ______________ Signature Date
_____________ Employee ID
New Hire
Return completed forms to: UW Health Human Resources - Benefits Mail Code: 2409-HRFax: (608) 263-5778
Revised 9/2007
New Hire
Long Term Disability (LTD) Benefit TTaaxx OOppttiioonn EEnnrroollllmmeenntt FFoorrmm
Long Term Disability (LTD) Insurance is provided to UWMF employees with a minimum of 0.75 FTE (30 hours per week or more) and UWMF mid-level providers with a minimum of 0.50 FTE (20 hours per week or more). Eligibility is the first of the month following one month of employment. UWMF pays the premium for the LTD benefit; however, the employee must pay the tax on this benefit in one of two ways:
Post-Tax Option UWMF will reimburse the employee for the cost of the premium in addition to their regular compensation. The pay code LTDAT willappear on his/her paycheck as income, equal to the amount of the disability insurance premium. That amount is then subtracted fromhis/her paycheck. This process is simply to calculate the federal tax on the premium.
The amount of the premium is based on the employee’s prior year W2 wages. If newly eligible for the plan, the premium is based on theemployee’s annualized current rate of pay.
The tax impact on the employee will be based on the LTD premium that UWMF is compensating the employee.
If the employee is disabled for more than 90 consecutive days and is approved to collect LTD benefits, he/she will not have income taxdeducted from his/her disability check. The disability check will not be income to the employee and therefore does not have to beclaimed on the employee’s tax return at year-end.
Pre-Tax Option UWMF will pay the LTD premium on behalf of the employee. The pay code LTDBT will appear on his/her paycheck as an employer paidbenefit.
The amount of the premium is based on the employee’s prior year W2 wages. If newly eligible for the plan, the premium is based on theemployee’s annualized current rate of pay.
If the employee is ever unable to work due to a disability and is approved to receive LTD benefits, the disability benefit would be taxableincome. This is because the employee chose not to pay the taxes through payroll deduction. The employee would have to claim thatmoney as taxable income on their annual tax return and pay taxes on it at the end of the year.
The employee may choose whichever option best suits their needs. However, UWMF strongly encourages employees to elect the Post-Tax Option. There may be less of a financial strain to an employee if he/she chooses to pay the tax on the benefit while working and receiving a steady paycheck rather than pay the tax through his/her annual tax return.
Keep in mind that LTD Insurance is similar to car insurance – you don’t expect to use your car insurance, but it’s there if you need it. The same goes for LTD – you don’t expect to use your LTD benefit, but it is there if you need it. If you elect the Post-Tax Option, but do not use your LTD benefit, you do not get the taxes paid on the benefit back. Again, this is just like car insurance. If you don’t make a claim against your car insurance, you won’t get your premiums back.
Changes can only be made to the employee’s election during the annual open enrollment period.
Please choose the option you prefer below:
LTD Post-Tax Option: I elect to participate in the Post-Tax Option for the Long Term Disability benefit. I understand that UWMF will reimburse me for the premium, and that taxes will be calculated on that premium. I also understand that if I were to claim LTD and receive disability payments, I will not have to pay income tax on the disability income.
LTD Pre-Tax Option: I elect to participate in the Pre-Tax Option for the Long Term Disability benefit. I understand that UWMF will pay for the LTD premium on a pre-tax basis. I will not see a premium deduction, nor the added compensation on my paycheck related to LTD. I also understand that if I were to claim LTD and receive disability payments, I will have to claim the disability income as taxable income on my annual tax return.
_______________Employee Name (please print) Emp ID
_______________Employee Signature Date
Return completed forms to: UW Health Human Resources - Benefits Mail Code: 2409-HRFax: (608) 263-5778
KBG354
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Cannot enroll in a Health Care Flexible Spending Account if enrolled in a High Deductible Health Plan. If your FTE is .38 or greater you are eligible to enroll in Dependent Daycare regardless of medical election.
Employee Contribution
Note: I understand my Health Savings Account (HSA) will be set up effective the first day of the month following the date this worksheet is signed.
HDHP Coverage Level (*circle one)
Single / Family
Health Savings Account (HSA) Data Collection WorksheetPlease complete and submit this worksheet to your employer. This is an internal document used by your employer for data collection purposes. Worksheets submitted to Discovery Benefits will not be processed.
*=Required Fields
Step 1: Account Holder Information
Step 2: HSA Election for Current Tax Year
Step 3: Authorized Signature
*Employer Name (Do not abbreviate)
*Account Holder Name (First, MI, Last)
*Employee ID Number
*Social Security Number
--
- -
*Physical Address (Cannot be PO Box)
*Email Address
*Date of Birth (mm/dd/yyyy) *Hire Date (mm/dd/yyyy)
$(to be deducted each pay period) (mm/dd/yyyy)*Per Pay Period Amount:
Employer Contribution: Check with your employer to determine if you will receive employer contributions. Both employee and employer contributions will be applied to your annual IRS maximum.
Note: There may be tax consequences if HSA contributions exceed the IRS governed limit. To determine the maximum HSA contribution for the current tax year visit www.discoverybenefits.com.
*HDHP Coverage Date:
By signing this application I represent that: 1) I am covered under a high deductible health plan (HDHP); 2) I am not covered by any other health plan that is not an HDHP; 3) I am not enrolled in Medicare; 4) I cannot be claimed as a dependent on another person’s tax return; and 5) I have read and agreed to the HSA Custodial Agreement and Disclosure Statement. I understand that if my spouse is enrolled in a general-purpose FSA (a non-HDHP), I am not eligible to contribute to an HSA. I understand my Health Savings Account will be set up effective the first day of the month following the date the Enrollment Application is signed. Further, I understand that my Health Savings Account cannot be effective prior to my HDHP coverage date.
*Signature of Account Holder *Date
Revised 12/22/14
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Staff can only enroll in a HSA if they're enrolled in a High Deductible Health Plan (HDHP)
Health Savings Account (HSA) Death Beneficiary Change FormThis form is to make changes to beneficiary designations. Please note: in order to process this form, notarization is required.
*=Required Fields
Step 1: Account Holder Information
Step 2: Designation of Death Beneficiary/Beneficiaries
Step 3: Marital Status
*Account Holder Name (First, MI, Last)
*Employer Name (Do not abbreviate) Employee ID
New Death Beneficiary(ies): The following individual(s) or entity shall be my primary and/or contingent death beneficiary(ies). If neither primary nor contingent is indicated, the individual or entity will be deemed to be a primary death beneficiary.
Replace Death Beneficiary(ies): I designate the individual(s) or entity named below as my primary and/or contingent death beneficiary(ies) of this HSA and hereby revoke all prior death beneficiary(ies) designations, if any, made by me.
Add Death Beneficiary(ies): I designate the individual(s) or entity named below as my primary and/or contingent death beneficiary(ies) of this HSA. This list supplements, but does not replace, the death beneficiary(ies) previously designated by me on the date specified.Note: When adding death beneficiaries, if the share % of previously designated death beneficiary(ies) changes, restate all death beneficiaries and the corresponding share % if the previous percentages are no longer correct.
If neither primary nor contingent is indicated, the individual or entity will be deemed to be a primary death beneficiary. If any primary or contingent death beneficiary dies before me, his or her interest and the interest of his or her heirs shall terminate completely, and the percentage share of any remaining death beneficiary(ies) shall be increased on a pro rata basis. If more than one primary death beneficiary is designated and no distribution percentages are indicated, the death beneficiaries will be deemed to own equal share percentages in the HSA. Multiple contingent death beneficiaries with no share percentage indicated will also be deemed to share equally. If no primary death beneficiary(ies) survives me, the contingent death beneficiary(ies) shall acquire the designated share of my HSA.
I am the spouse of the above-named HSA Account Beneficiary. I acknowledge that I have received a fair and reasonable disclosure of my spouse’s property and financial obligations. Due to the important tax consequences of giving up my interest in this HSA, I have been advised to see a tax professional. I hereby give the HSA Account Beneficiary any interest I have in the funds or property deposited in this HSA and consent to the death beneficiary designation(s) indicated above. I assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by the Custodian.
Name Social Security Number
Birth Date Address Primary or Contingent
Relationship Share %
Primary
Primary
Contingent
Contingent
I am not married: I understand that if I become married in the future, I must complete a new HSA Designation of Death Beneficiary Form.
I am married: I understand that if I choose to designate a primary death beneficiary other than my spouse, my spouse must sign below and have his/her signature notarized.
Spouse Signature Date� � � � � � � � � � � �
KBG354
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Staff can only enroll in a HSA if they're enrolled in a High Deductible Health Plan (HDHP)
Step 4: Spouse’s Signature Notarization (only required if spouse is not the designated beneficiary)
Step 5: Authorized HSA Account Holder Signature
State of
Notary Public Signature (seal)
County of
On this, the day of , 20 , before me a notary public, , personally
appeared , satisfactorily proved to be the person whose name is subscribed to the within instrument, and acknowledged that
he/she executed the same for the purposes therein contained.
In witness hereof, I hereunto set my hand and official seal.
If this HSA is being established with a regular contribution, I certify that I am covered by a qualified high deductible health plan (HDHP), and that I am not covered by a health plan other that an HDHP that provides any of the same benefits as an HDHP. If this HSA is being established with a rollover or transfer contribution, I certify that the rollover or transfer assets are from another HSA or Archer Medical Savings Account (MSA). I certify that the information provided by me on the Application is accurate, and that I have received a copy of the Application and Custodial Agreement and Disclosure Statement and amendments thereto. I assume sole responsibility for all consequences found in the Application and Custodial Agreement and Disclosure Statement. I understand that I may revoke the HSA on or before seven (7) days aber the date of establishment. I have not received any tax or legal advice from the Custodian, and I will seek the advice of my own tax or legal professional to ensure my compliance with related laws. I release and agree to hold the HSA custodian harmless against any and all claims or losses arising from my actions.
*HSA Account Holder Signature *Date
Revised 5/11/15
KBG354
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Staff can only enroll in a HSA if they're enrolled in a High Deductible Health Plan (HDHP)
Combination FSA Data Collection Worksheet
Please complete and submit this worksheet to your employer. This is an internal document used by your employer for data collection purposes. Worksheets submitted to Discovery Benefits will not be processed.
*= Required Fields
Step 1: Participant Information
*Employer Name (Do not abbreviate) *Employee Identifier Number
- -
*Participant Name (First, MI, Last) *Social Security Number
*Participant Mailing Address Email Address (If provided, all notifications will be sent via email)
*City *State *Zip
- -
Day Telephone *Birth Date (mm/dd/yyyy) *Hire Date (mm/dd/yyyy)
*Hire Date (mm/dd/yyyy)
Gender (Please circle one): Male / Female
Step 2: Employee Premiums If you have a payroll deduction for insurance premiums, eligible premiums will be deducted before taxes are calculated. You will automatically be enrolled in this portion of your Section 125 Plan. However, if you wish, you may opt out of the Employee Premium Conversion part of the Plan by contacting your HR Department and filling out the waiver form. *Please Note: Insurance premiums are not eligible for reimbursement with your Medical Spending Account.
Step 3: Enrollment and Election Information
*Plan Type (if enrolled in an HSA, you are eligible for Dependent Care FSA.)
Combination FSA Account
Limit set by employer up to IRS maximum
*Annual Election (if employer funded, note ‘ER’ next to amount) $
*Number of Pay Periods (if enrolling mid-year, please enter the number of remaining
pay periods within the plan year) ÷
*Per Pay Period Amount (to be deducted each pay period) =
*Date of First Payroll (mm/dd/yyyy)
*Participant Effective Date (mm/dd/yyyy)
*Pay Frequency (please circle one)Monthly / Semi-Monthly / Bi-Weekly 24 / Bi-Weekly 26 / Weekly / Other
Step 4: Authorization I authorize my employer to reduce my pay on a per pay period basis as indicated above. I understand my reduction is for one flex plan year and that I cannot change or revoke my election unless I experience a qualifying event in accordance with Internal Revenue Code Section 125 and submit my request within a reasonable amount of time as deemed by the IRS and my employer. I am aware of the plan's forfeiture provision and that my Social Security and federal unemployment benefits may be reduced because of my reduced salary for tax purposes. Further, I authorize the release of any information necessary to substantiate claims submitted against my Flexible Spending Account.
Step 5: Refusal (**NOTE: only complete this step if you are NOT electing to enroll in a Flexible Spending Account)I understand that if I choose not to participate in a Flexible Spending Account (FSA), I cannot enter the program until the next plan year unless I experience a status change in accordance with Internal Revenue Code Section 125 and submit the change within 30 days of the status change.
Marital Status (Please circle one): Married / Single
*Participant Signature *Date
*Participant Signature *Date
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Staff can only enroll in a Combination FSA Plan if they're enrolled in a High Deductible Health Plan (HDHP)
Enroll in LifeLock Identity Theft Protection
WHAT IS IDENTITY THEFTThieves pretend to be you to
take over or open new accounts, file fake tax returns,
rent or buy properties, or do other criminal things in your
name.
See reverse for more information and rates.
Alert modified for demonstration purposes.
When a threat is detected,LifeLock notifies members by phone, text or email.§
HOW LIFELOCK WORKSLifeLock protection alerts you to suspicious activity† and helps fix
ID theft issues with dedicated US-based specialists. We'll
spend up to $1M to help make things right.‡
WHY LIFELOCKFree credit monitoring services
alone aren't enough. DIY identity monitoring isn't realistic. Your bank
only monitors transactions on existing accounts. These are just a
few reasons to choose LifeLock Identity Theft Protection.
MPA0437
QUESTIONS TO CONSIDER
Do I really need to worry about identity theft?Yes. Identity theft is America’s fastest growing crime.1 Simply put, it’s when someone uses your personal information for their gain and your loss.
Why is restoring my identity so difficult?Proving that ‘you are you’ can be time-consuming and expensive. Filing paperwork, disputes, and insurance claims can take weeks, months and even years. LifeLock’s team of specialists will work with you to help clear your name, retain lawyers and other experts if needed, and pay court fees.
Doesn’t my bank’s credit card service have me covered?Your bank monitors transactions on your existing account. They may not see accounts opened using your identity at another bank – or an application for a student loan, welfare check, or cellular plan in another state either.
Can’t I just wait for identity theft before getting LifeLock® protection?Your identity is exposed every day, If your personal information is stolen, it may show up on the dark web months before you’re notified of a data breach. Plus, thieves may wait years before using your personal info.
•
•
•
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No one can prevent all identity theft.† LifeLock does not monitor all transactions at all businesses.§ Fastest alerts require member’s current email address. Phone alerts made during normal local business hours.
The relevant employee benefitCHOOSE THE LIFELOCK SERVICE THAT’S RIGHT FOR YOU.
LIFELOCK BENEFIT ELITE (only available as
a payroll deducted employee benefit)
includes searching over a trillion data points
every day for potential threats to your identity
and to financial assets – your 401(k) and
investment accounts.†
Also includes scanning for misuse of your
Social Security number, change of address
and court records scanning for use of your
identity to commit crimes.
LIFELOCK ULTIMATE PLUS™ service
provides some peace of mind knowing you
have LifeLock’s most comprehensive identity
theft protection available. Enhanced services
include bank account application and
takeover alerts, online credit reports and
credit scores.†
LIFELOCK JUNIOR® (if dependents under
age 18 are enrolled) protection helps safeguard your child’s Social Security number and good name with proactive identity theft protection designed specifically for children.††
No one can prevent all identity theft. † LifeLock does not monitor all transactions at all businesses.
* Must agree to the terms and conditions at LifeLock.com/terms.
** Children under the age of 18 will receive a product designed specifically for minors, LifeLock Junior service. Enrollment in LifeLock service is limited to employees and their eligible dependents.
†† LifeLock Junior® membership is available as an added membership to an adult LifeLock plan.
‡ Service Guarantee benefits for State of New York members are provided under a Master Insurance Policy issued by State National Insurance Company. Benefits for all other members are provided under a Master Insurance Policy underwritten by United Specialty Insurance Company. Under the Service Guarantee LifeLock will spend up to $1 million to hire experts to help your recovery. Please see the policy for terms, conditions and exclusions at LifeLock.com/legal.
You will receive a welcome email on your benefit effective date with instructions on how to take full advantage of your LifeLock membership!
SERVICE FEATURES LifeLock Benefit Elite
LifeLock Ultimate Plus™
LifeLock Identity Alert® System†
Lost Wallet Protection
Address Change Verification
Black Market Website Surveillance
LifeLock Privacy Monitor™ Tool
Reduced Pre-Approved Credit Card Offers
Live Member Service Support
Identity Restoration Support
Fictitious Identity Monitoring
Court Records Scanning
Data Breach Notifications
Investment Account Activity Alerts†
$1 Million Service Guarantee‡
Credit Card, Checking & Savings with Account Activity Alerts†
Online Annual Credit Report
Online Annual Credit Score
Checking and Savings Account Application Alerts†
Bank Account Takeover Alerts†
Credit Inquiry Alerts†
Online Annual Tri-Bureau Credit Reports & Scores
Monthly Credit Score Tracking
File-Sharing Network Searches
Sex Offender Registry Reports
Priority Live Member Service Support
State Zip
Legal Name
Social Security Number
Address
City
Phone Number (
E-mail
Spouse Name
Dependent Name
Dependent Name
Dependent Name
Birthdate / /- -
SSNSSN - Gender M F DOB / /
- SSN - Gender M F DOB / /
SSNSSN - Gender M F DOB / /
SSN - - Gender M F DOB / /
) -
By signing this form, you represent that you have the authority to enroll those dependents indicated above in LifeLock services and you further agree to LifeLock’s Terms and Conditions which can be found at www.lifelock.com/terms on behalf of yourself and any other members of your family you are enrolling. Please see your HR department for the cancellation policy or a copy of LifeLocks Terms and Conditions.
Employee Signature: Date Signed:
Important Message: Without complete information, your enrollment in LifeLock service will be delayed until complete information is received.
Social Security #:___________________________________ Employee #: ________________________________
Pursuant to the provisions of the plan permitting the designation of a beneficiary or beneficiaries by a participant, I hereby designate the following person or persons as primary and secondary beneficiaries of my accrued benefit under the plan payable by reason of my death:
PRIMARY BENEFICIARY(IES): Please attach another sheet of paper if necessary.
____________________________________________ _______________ ____________________________________ Name Relationship Address ____________________________________________ _______________ ____________________________________ Social Security Number Birthdate City, State, Zip Code
____________________________________________ _______________ ____________________________________ Name Relationship Address ____________________________________________ _______________ ____________________________________ Social Security Number Birthdate City, State, Zip Code
SECONDARY BENEFICIARY(IES): Please attach another sheet of paper if necessary.
____________________________________________ _______________ ____________________________________ Name Relationship Address ____________________________________________ _______________ ____________________________________ Social Security Number Birthdate City, State, Zip Code
____________________________________________ _______________ ____________________________________ Name Relationship Address ____________________________________________ _______________ ____________________________________ Social Security Number Birthdate City, State, Zip Code
I RESERVE THE RIGHT TO REVOKE OR CHANGE ANY BENEFICIARY DESIGNATION. I HEREBY REVOKE ALL PRIOR DESIGNATIONS (IF ANY) OF PRIMARY AND SECONDARY BENEFICIARIES.
The trustee will pay all sums payable under the plan by reason of my death to the primary beneficiary. If he or she survives me, and if no primary beneficiary survives me, then to the secondary beneficiary, and if no named beneficiary survives me, then the trustee will pay all amounts in accordance with the plan’s death beneficiary provisions.
_________________________________________________ _________________________________________________ Date of this Designation Signature of Participant
I am married I am not married
Designation of Beneficiary The UWMF, Inc. Employee & Physician
Retirement Plans
NOTE: IF YOU ARE MARRIED AND YOU DO NOT NAME YOUR SPOUSE AS YOUR ONLY PRIMARY BENEFICIARY, YOUR SPOUSE’S SIGNATURE MUST BE NOTARIZED ON THE UWMF, Inc. Employee & Physician Retirement Plans Spousal Consent Form. Return completed form to: UW Health Human Resources - Benefits Mail Code: 2409-HRFax: (608) 263-5778
COMPLETE THIS FORM ONLY IF YOU DO NOT LIST YOUR SPOUSE AS YOUR PRIMARY BENEFICIARY.
The UWMF, Inc. Employee & Physician Retirement Plans
Spousal Consent FormI, the undersigned spouse of __________________________________________________________________named in the foregoing
(Participant/Employee Name – please print) “Designation of Beneficiary”, hereby certify that I have read the Designation of Beneficiary and fully understand the property subject to the designation is my spouse’s benefit under the Plan, in which I possess a beneficial interest, provided I survive my spouse. Being fully satisfied with the provisions of the designation, I hereby consent to and accept the beneficiary designation, without regard to whether I survive or predecease my spouse. This consent is irrevocable unless my spouse changes the designation. If my spouse changes the designated (choose either a or b)
_____ (a) I understand I must sign a similar consent to agree with any changes in the designation, or my consent is no longer effective; or
_____ (b) I waive my right to withhold my consent to a change in designation. I understand that I do have the right to limit my consent to the specific beneficiary designated on the life insurance or request for change form by checking line (a).
I have executed this consent this _________ day of ________________________________, 20_______.
_____________________________________________Signature of spouse of participant
Witness by Plan Representative
Signature of spouse for consent witnessed this ______ day of _________________________, 20______.
Before me, as the undersigned Notary Public, personally appeared _________________________________ who executed the above Spousal Consent as a free and voluntary act.
In witness whereof, I have signed my name and affixed by official notarial seal this _______ day of _______________________, 20_______.
_____________________________________________(SEAL) Notary Public
My commission expires:__________________________
Note: If you are married and you do not name your spouse as your only primary beneficiary, your spouse’s signature must be notarized on this page. Return completed form to: UW Health Human Resources - Benefits Mail Code: 2409-HRFax: (608) 263-5778
