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Find all benefit forms in one place - ACH, FSA forms, Domestic Partner Affidavits, and more. 

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Plan Documents

Find info about specific benefits, costs, limitations/expectations, and more.

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Insurance Overviews

Are you looking for your benefit category and what insurance you may be eligible for?

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Other Resources

Instructional videos, benefit scenarios, benefit explanation docs, and more.

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Below is where you will find all of the Benefits Office's forms, plan documents, insurance overviews, and many more resources. 


Automatic Withdrawal Authorization (pdf)
The University Billing Office's form is used to authorize the automatic withdrawal of insurance premiums from your checking or savings account to cover billed expenses for retirees, temporary employees, students, and those on COBRA. 

Adding or making changes to beneficiaries can be done once a month on Employee Self Service under Benefits & Wellness >> Benefits >> Manage Beneficiaries.

However, if the following situation(s) arises, you will need to fill out a paper Beneficiary Designation Form (pdf) and submit it to our office at benefits@uiowa.edu

  • If you are trying to designate a trust or an estate;
  • If you are electing a flat amount for one of your beneficiaries instead of a percentage;
  • If you have already made a change on Employee Self Service during the month and need to make another change;
  • or it is the Annual Open Enrollment Period, and the Manage Beneficiary application is closed.

The Uniform Transfers to Minors Act (UTMA) allows you to transfer financial assets to a minor without establishing a trust. Use the Principal form below if you are listing a minor as a beneficiary to your Life Insurance policies.

Please submit your form online through Employee Self Service.

  • Once logged in, select the "Benefits & Wellness" link from the left-side menu >> select "Benefits" >> then select the link "Benefits Change Request"

Use this form to notify the Benefits Office of a qualifying event.

These forms are used to request the donation of hours due to your own catastrophic illness or that of a family member to be completed by the employee and their physician.

If you would like to donate some of your unused vacation time to an employee in need, please fill out the form below. You will need to enter a recipient for your donated time. If you do not have anyone specific, you can find a list of employees in need on our Cat Leave site.

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

  • Common Law Marriage Affidavit (pdf)
    This form is for use by Faculty, Professional and Scientific, Merit Staff, House Staff, Employed Graduate Student, Postdoctoral Scholars/Fellows.

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

If you and your spouse/domestic partner both work at the University of Iowa in benefits-eligible positions and have dependent children who require coverage under your policy, you may be eligible for the Double Spouse Credit.

Depending on what health plan (UISelect and UIChoice) you choose to enroll in, you and your spouse/partner can receive family health coverage for free or minimal cost.

If you are not covering dependent children, you and your spouse/domestic partner should sign up for Employee Only coverage since it is also provided at no or little cost depending on which health plan you choose.

Double Spouse Credit Form (pdf)

Enrolling or changing your contribution amount:

Please complete the Salary Reduction Agreement form linked below to begin, end, or change your Flexible Spending Account contribution amount. 

Forms for HealthEquity can be found through your member portal:

(Pay Me Back Claim Form, Letter of Medical Necessity Form, and Dependent Care Pay Me Back Claim Form)

  1. Log in to Employee Self-Service with your Hawk ID and password.
  2. Select Benefits & Wellness
  3. Under Flex Spending, choose the "HealthEquity Health and Dependent Care FSA" link.
  4. Once in your HealthEquity participant portal, select the "General Forms" link under "MANAGE ACCOUNT."

You may purchase an individual life insurance policy if your group or voluntary term insurance ends and you qualify for individual purchase (conversion/portability). Please visit the Group or Voluntary Term Life Insurance accordion under the Plan Documents section of this page to read more about this process. 

Group Term Life application:

Voluntary Term Life application:

Form is available on Employee Self Service >> My Self Service >> Personal Information >> Information Release Form

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

Visit the Privacy Information page to learn more about how medical information about you may be used and disclosed and how you can get access to this information.

Personal Health Information Release Form (pdf)

An employee must be at least 57 years old with 15 years of service in order to participate in this program. The request must go through the appropriate administrative offices for final approval. 

Request to Participate in the Phased Retirement Program (pdf)

  • Temporary Insurance with Department Contribution
    Temporary Employees (50% or Greater) Request for Payment of Health Insurance Contributions.
    Departments use this form if they wish to contribute to the health insurance premiums of a temporary Faculty or Staff employee.

  • Voluntary Retirement Savings Program (VRSP), 2022 Calculation Worksheet (xlsx)
    Available on Employee Self Service
    Use this file to determine if you are eligible for the VRSP and if so, how much you're eligible to contribute.
  • Voluntary Retirement Savings Program (VRSP), Salary Reduction Agreement
    Available on Employee Self Service - use the online form to begin, end, or change your VRSP contribution amount
    Note: If you are a bi-weekly employee and wish to participate, please contact University Benefits at benefits@uiowa.edu.

Plan Documents & Manuals

2024 Documents (coming soon)

  • 2024 UIGRADCare Summary of Benefits and Coverages (pdf)
  • 2024 UIGRADCare Coverage Manual (pdf)

2023 Documents

Other Plan Documents


Please visit the forms section on the Benefits Resources page under the "Life Insurance Conversion Policy" accordion item to fill out a voluntary term life portability application. 

The Voluntary Vision insurance is administered by World Insurance Associates, LLC (formerly Two Rivers Insurance Services).
The annual open enrollment period for the voluntary vision benefit is always January and February. The effective date for all enrollments, changes, and cancellations is April 1st, with the payroll authorization also renewing April 1st. Once you are enrolled, you must remain on the vision insurance for one contract year, from April 1st through March 31st.

Two vision plans offered:

Provider details can be found under "More Information" on the dedicated UI Voluntary Vision website.

Insurance Overviews

Graduate students who hold an assistantship of at least 25% time or a fellowship of at least $5,000 for the semester or $10,000 per academic year, and are registered for classes, are eligible to receive a contribution from the university toward the cost of health and dental insurance coverage. 

2023-2024 Overview

Graduate students and health science majors may choose between the Student Health Insurance Plan (SHIP) or UIGRADCare. 

2023-2024 Overview

Please visit the undergrad student insurance pages for details.

Other Resources

When adding a new dependent (e.g., spouse, domestic partner, child) to your health and/or dental insurance, you will be required to submit proof of their eligibility. Below is a printable list of what documents are needed for specific verification of your dependents. 

Connect not only virtually but personally with providers dedicated to your health, 24/7. See someone who gets you. Gets what you need. And gets you on with your day.

Wellmarks Doc on Demand Flyer (pdf)

Below is the Open Enrollment 2023 "How to Enroll in Benefits on Employee Self Service." 

As a benefit-eligible employee, you have two health plans to choose from, UIChoice and UISelect. Below are two real-world examples of costs for an employee with family coverage (Robert) or single coverage (Selena) when using either UISelect or UIChoice in 2023.