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University Benefits — Forms

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Authorization for Pre-Payment of Insurance Premiums ( PDF version PDF )

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

Beneficiary Designation Form ( PDF version PDF )

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

Benefit Change Request ( PDF version PDF ) ( MS WordWord )

Use this form to notify the Benefits Office of a Qualifying Event if you are Faculty, Professional & Scientific, or Merit Supervisory Exempt 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.

Common Law Marriage Affidavit ( PDF icon 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 ( link iconSelf Service ) ( link icon PDF )

Direct Deposit ( link iconSelf Service ) ( pdf icon 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.

 

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

Group Supplemental Retirement Annuity (GSRA)

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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 ( link iconSelf Service ) ( pdf icon PDF )

Health Insurance

 

Life Conversion Policy Application ( PDF icon 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 ( link icon Self-Service )  (See also Workers' Compensation)

No Restricted Work Available Form(See Workers' Compensation)

Personal Health Information Release Form ( pdf icon PDF )

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 icon PDF )
  • Short Form ( pdf icon PDF

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Request for Payment of Health Insurance Contributions for Temp Employee( pdf icon PDF )

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

Restricted Work Assignment Form(See Workers' Compensation)

Spending Accounts Request for Reimbursement

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

Spending Accounts Salary Reduction Form (PDF)

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Workers' Compensation Forms

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

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