Human Resources - University Benefits

Benefits Home >> Forms

 

Adult Children (Certification of)

This form is used to certify adult children are eligible to be enrolled on your insurance (PDF)

2013 Form

Authorization for Pre-Payment of Insurance Premiums ( PDF )

This form is used to authorize automatic insurance premium deductions for retirees, temporary employees, students, those on COBRA, etc.

Beneficiary Designation Form ( PDF ) ( Self-Service )

Use this form to designate beneficiaries for your Group and Supplementary Life Insurance plans and the Accidental Death and Dismemberment insurance.

Benefit Change Request

Use this form to notify the Benefits Office of a Qualifying Event

• Faculty, Professional & Scientific, Merit Supervisory Exempt, or House Staff:
  ( PDF ) ( Self-Service )
• Merit Staff: ( PDF )

Catastrophic Leave Donation Forms

This form is used to donate your vacation hours to another employee in need of leave due to a catastrophic illness of their own or a family member.

• Employee ( PDF )
• Family ( PDF )

Application for Catastrophic Leave Donations Forms

This form is used to request the donation of hours due to your own catastrophic illness or that of a family member.

• Employee ( PDF )
• Immediate Family Member ( PDF )

Certification of Adult Children

This form is used to certify adult children are eligible to be enrolled on your insurance (PDF)

2012 Form

Common Law Marriage Affidavit ( PDF )

Declaration of understanding that a common law marriage is legally recognized as a marriage.

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Dependent Care Spending Account Reimbursement Form

Request reimbursement from a spending account using the Employee Self Service web site or this
hard copy paper form.

Dependent Care Spending Account reimbursement forms ( Self Service ) ( PDF )

Dependent Care Spending Account reimbursement - Receipt template ( pdf)

Direct Deposit ( Self Service ) ( PDF )

Set up and maintain your direct deposit information for any bank in the continental United States using the Employee Self Service web site or hard copy paper form.

Domestic Partner Affidavits

Declaration of domestic partners and criteria for eligibility for certain insurance benefits under The University of Iowa benefits program.  Also affidavit of termination of domestic partner relationship.

• Faculty, P&S, and MSE ( PDF )
• Merit ( PDF )
• Students ( PDF )
• Termination of Partnership ( PDF )

Double Spouse Credit

When a husband and wife (or domestic partners) are both employed by The University of Iowa, they may elect to take advantage of the Double Spouse Credit. The change to Double Spouse Credit may be made at the time of hire, open enrollment, or the first of the month following a qualifying event such as marriage or declaration of domestic partnership.

• Faculty, Professional and Scientific, and Merit Supervisory Exempt Form ( PDF )
• Merit Staff Double Spouse Form

Employed Graduate Student Health/Dental Insurance Application

Employed Graduate Student   ( PDF )

First Report of Injury Form ( Self-Service )  (See also Workers' Compensation)

Graduate Student Health/Dental Insurance Application (non-employed)

• Graduate Students and Health Science Majors Health Insurance Application

Group Supplemental Retirement Annuity (GSRA)

See Voluntary Retirement Savings Program (VRSP)

Health Care Spending Account Reimbursement Form

Request reimbursement from a spending account using the Employee Self Service web site or this
hard copy paper form.

Health Care ( Self Service ) ( PDF )

Health Insurance

• Wellmark/Blue Cross Patient Claim form #C-5321f
• Merit Staff - Prescription Reimbursement Claim form
• Faculty, P&S, Merit Supervisory Exempt Staff - Prescription Reimbursement Claim form - CHIP II only
• Faculty, P&S, Merit Supervisory Exempt Staff - Prescription Reimbursement Claim form - UIChoice
• International Claim Form
• Undergraduate Student Health Insurance Application (Except Health Science Majors)
• Employed Graduate Student Health & Dental Insurance Application
• Graduate Students and Health Science Majors Health Insurance Application
• Students who have recently graduated or Students who have left the University Health Insurance Application
• Proof of Coverage/Exemption Form-International and Health Science Students (pdf)

Health Science Major Student Health/Dental Insurance Application

• Health Science Majors Health Insurance Application

Life Conversion Policy Application ( PDF)

You may purchase an individual life insurance policy if your group term insurance ends and you qualify for individual purchase (conversion) as described in your booklet or certificate.

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Missed Time Weekly Report ( Self-Service )  (See also Workers' Compensation)

No Restricted Work Available Form(See Workers' Compensation)

Personal Health Information Release Form ( PDF ) (Self-Service)

Use this form to allow the benefits office to discuss your benefits with someone you choose, such as a spouse, parent, partner, secretary, etc.

Notice of Privacy Practices - This notice describes how medical information about you may be used and disclosed and how you can bet access to this information.  More information....

• Long Form ( PDF )
• Short Form ( PDF)

Prescription Reimbursement Forms

• Faculty, P&S, Merit Supervisory/Exempt, Merit Staff, & Student Insurance
• Faculty, P&S, Merit Supervisory Exempt Staff - Prescription Reimbursement Claim form - CHIP II only

Proof of Coverage Form

• Proof of Coverage/Exemption Form-International and Health Science Students (pdf)

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Restricted Work Assignment Form(See Workers' Compensation)

Retirement Election Form(  PDF)

Employees use this form within 60 days of their hire date in order to select the retirement program in which they want to participate.

Retirement - Phased

Request to Participate in Phased Retirement Form

Retirement Plans Release of Funds Waiver

Terminated employees use this form if they wish to withdraw up to 100% of their accumulation in his/her non-IPERS University Retirement Plan at the University.   (PDF)

Salary Reduction Agreements

• Spending Accounts Salary Reduction Form 2012 (PDF)
• Salary Reduction Agreement for Spending Accounts 2013 form.
• Voluntary Retirement Savings Program Salary Reduction Agreement ( PDF ) -- Use this form to begin, end, or change your VRSP contribution amount.
  

Spending Accounts Request for Reimbursement

Request reimbursement from a spending account using the Employee Self Service web site or this hard copy paper form.

• Dependent Care ( Self Service ) ( PDF )
• Health Care ( Self Service ) ( PDF )
• Spending Accounts Salary Reduction Form (PDF)

Temporary Employees (50% or Greater) - Request for Payment of Health Insurance Contributions (PDF )

Departments use this form if they wish to contribute to the health insurance premiums of a temporary Faculty member or Professional & Scientific employee.

Undergraduate Student Health Insurance Applications

• Undergraduate Student Health Insurance Application (Except Health Science Majors)
  
• Health Science Majors Health Insurance Application

Voluntary Retirement Savings Program

• Calculation Worksheet (2012 PDF and 2013 PDF) -- Use this form to determine if you are eligible for the VRSP and if so, how much you’re eligible to contribute
• Salary Reduction Agreement ( PDF ) -- Use this form to begin, end, or change your VRSP contribution amount.
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Workers' Compensation Forms

• First Report of Injury Form ( Self-Service )

   

  To be completed by the employee/supervisor on the Employee Self Service site under HR Applications within 24 hours of report of injury.

• Mileage Reimbursement Form ( PDF )

   

  To be completed by the employee and submitted on a monthly basis to Sedgwick CMS for reimbursement of necessary travel expenses (ie. mileage, parking, etc.) related to a covered workers’ compensation claim. The employee is encouraged to keep a copy of this document for their records.

• Missed Time Weekly Report ( Self-Service )

   

  To be completed by designated departmental staff to report employee hours of work, and restricted work assignments/hours etc.

• Restricted Work Assignment Form ( PDF )

To be completed by designated departmental staff and employee. Information outlines the restricted work assignment due to work-related illness/injury.

• No Restricted Work Available Form ( PDF )

  To be completed by department outlining that accommodations for current restrictions not available.