Adult Children (Certification of)
This form is used to certify adult children are eligible to be enrolled on your insurance (PDF)
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:
(- Merit Staff: (
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.
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.
Certification of Adult Children
This form is used to certify adult children are eligible to be enrolled on your insurance (PDF)
Common Law Marriage Affidavit ( PDF )
Declaration of understanding that a common law marriage is legally recognized as a marriage.
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 (
Dependent Care Spending Account reimbursement - Receipt template (
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.
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 (
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)
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 (
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.
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....
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
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
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 Agreement
for Spending Accounts 2013 form.
Use this form to begin, end, or change your Spending Account contribution amount.
- 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 ( 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.
Top of Page
- 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.