University of Wisconsin System



Employee: FORMTEXT ?????Employee Spouse: FORMTEXT ?????SSN: FORMTEXT ?????Employee ID: FORMTEXT ?????SSN: FORMTEXT ?????DOB: FORMTEXT ?????Age: FORMTEXT ?????DOB: FORMTEXT ?????Age: FORMTEXT ?????Appt Date / Time: FORMTEXT ?????State Employee: Yes FORMCHECKBOX No FORMCHECKBOX Retirement Date(s): FORMTEXT ????? FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Phone Number:Home: FORMTEXT ????? Work: FORMTEXT ?????Seniority Date: FORMTEXT ?????Current Salary/Hourly Wage: $ FORMTEXT ?????Appt Type / Position Title: FORMTEXT ????? Basis/Appt % FORMTEXT ?????Department Code: FORMTEXT ?????Vacation Hours:VC: FORMTEXT ?????VN: FORMTEXT ?????Sick Leave Hours: FORMTEXT ????? FORMTEXT ????? hrs / pay periodBanked Leave Hours: FORMTEXT ?????Personal / Floating Holiday Hours: FORMTEXT ?????Comp Time Hours: FORMTEXT ?????Current Tax Filing Status: Federal- FORMTEXT ????? Additional- FORMTEXT ????? State- FORMTEXT ????? Additional- FORMTEXT ????? Benefit PlanMonthly DeductionCoverage Levels / Plan / TypeCommentsState Group Health Insurance $ FORMTEXT ?????Carrier: FORMTEXT ?????Type: FORMTEXT ?????Employer paid coverage will end on: FORMTEXT ?????. Coverage automatically continues at retirement and premiums will be paid by accumulated sick leave credits (see estimate) until exhausted. The currently monthly premium to maintain your current coverage in retirement is FORMTEXT ?????. You will receive new ID cards for your retiree coverage.You (and/or spouse) is/are required to enroll in Medicare Part B effective FORMTEXT ?????.Supplemental Dental Insurance$ FORMTEXT ?????Plan: FORMTEXT ?????Type: FORMTEXT ?????Coverage ends on: FORMTEXT ?????.Can continue indefinitely through direct payment to carrier. Vision Insurance $ FORMTEXT ?????Type: FORMTEXT ?????Coverage ends on: FORMTEXT ?????.Can continue indefinitely through direct payment to carrier. State Group Life InsuranceBasicSupplementalAddl: FORMTEXT ????? unit(s)Total Cost/Coverage:Spouse & Dependent: FORMTEXT ????? unit(s)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Spouse: $ FORMTEXT ????? Dependent: $ FORMTEXT ?????Coverage ends on: FORMTEXT ?????.Employee coverage automatically continues at retirement and premiums are taken directly from your annuity until age 65 (see estimate). Spouse & Dependent coverage ends at termination but can be converted to an individual policy at a higher premium.Individual & Family Life InsuranceEmployeeSpouse/Dom PartnerChildrenTotal Cost:$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Coverage ends on: FORMTEXT ?????.Can convert to an individual policy at a higher premium.UW Employees, Inc. Life Insurance $ FORMTEXT ?????$ FORMTEXT ?????Coverage ends on: FORMTEXT ?????.Can convert to an individual policy at a higher premium.University Insurance Assoc. Life Insurance$24.00 / Year$ FORMTEXT ?????Coverage ends Sept 30th following termination. Can continue through direct payment to carrier.Accidental Death & Dismemberment (AD&D) Insurance$ FORMTEXT ?????$ FORMTEXT ?????Type: FORMTEXT ?????Coverage ends on: FORMTEXT ?????.Can continue through direct payment to carrier. Income Continuation InsuranceStandardSupplemental$ FORMTEXT ?????$ FORMTEXT ?????Elimination Period / Category: FORMTEXT ?????Coverage ends at termination.Employee Reimbursement Account Medical AccountDependent Account$ FORMTEXT ????? $ FORMTEXT ????? Annual Pledge: $ FORMTEXT ?????YTD Contribution: $ FORMTEXT ?????Annual Pledge:$ FORMTEXT ?????YTD Contribution: $ FORMTEXT ?????Coverage ends: FORMTEXT ?????.Medical Account can be continued for full plan year if remaining calendar year contributions are deducted by final paycheck or are paid post-tax directly to ETF.Health Savings Account$ FORMTEXT ?????Annual Pledge: $ FORMTEXT ?????YTD Contribution: $ FORMTEXT ?????Contact plan administrator for information.UW Tax-Sheltered Annuity (TSA) 403(b) Program FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????YTD Contribution: $ FORMTEXT ?????YTD Contribution: $ FORMTEXT ?????YTD Contribution: $ FORMTEXT ?????Contact provider(s) for distribution information.Wisconsin Deferred Compensation (WDC) 457$ FORMTEXT ?????YTD Contribution: $ FORMTEXT ?????Contact provider for distribution information.Leave InformationWorksheet prepared as of your FORMTEXT ????? paycheck. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download